| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
255 |
179 |
$27K |
| D1120 |
Prophylaxis - child |
597 |
560 |
$26K |
| D0120 |
Periodic oral evaluation - established patient |
600 |
555 |
$25K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
147 |
113 |
$18K |
| D1206 |
Topical application of fluoride varnish |
759 |
705 |
$17K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
186 |
183 |
$10K |
| D0330 |
Panoramic radiographic image |
117 |
116 |
$8K |
| D0272 |
Bitewings - two radiographic images |
475 |
441 |
$8K |
| D1110 |
Prophylaxis - adult |
140 |
140 |
$6K |
| D0274 |
Bitewings - four radiographic images |
126 |
126 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
56 |
56 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
193 |
191 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
12 |
12 |
$155.94 |