| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
164 |
65 |
$7K |
| D1110 |
Prophylaxis - adult |
236 |
236 |
$7K |
| D0120 |
Periodic oral evaluation - established patient |
81 |
79 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
134 |
130 |
$531.50 |
| D1208 |
Topical application of fluoride, excluding varnish |
30 |
30 |
$465.00 |
| D0274 |
Bitewings - four radiographic images |
54 |
54 |
$394.50 |
| D0330 |
Panoramic radiographic image |
12 |
12 |
$200.00 |
| D0140 |
Limited oral evaluation - problem focused |
12 |
12 |
$180.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
59 |
58 |
$144.00 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
12 |
12 |
$125.00 |