| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
86 |
77 |
$8K |
| D1110 |
Prophylaxis - adult |
72 |
70 |
$5K |
| D0330 |
Panoramic radiographic image |
42 |
42 |
$4K |
| D0120 |
Periodic oral evaluation - established patient |
112 |
109 |
$4K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
76 |
72 |
$4K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
23 |
23 |
$2K |
| D1206 |
Topical application of fluoride varnish |
70 |
70 |
$2K |
| D1120 |
Prophylaxis - child |
53 |
53 |
$2K |
| D0274 |
Bitewings - four radiographic images |
57 |
56 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
12 |
12 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
13 |
13 |
$543.72 |
| D0220 |
Intraoral - periapical first radiographic image |
27 |
25 |
$268.32 |