| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
65 |
54 |
$5K |
| D4341 |
|
26 |
14 |
$4K |
| D0120 |
Periodic oral evaluation - established patient |
119 |
119 |
$3K |
| D1120 |
Prophylaxis - child |
62 |
62 |
$3K |
| D0330 |
Panoramic radiographic image |
92 |
92 |
$2K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
19 |
15 |
$2K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
24 |
17 |
$2K |
| D9110 |
|
29 |
28 |
$1K |
| D0272 |
Bitewings - two radiographic images |
118 |
118 |
$1K |
| D1206 |
Topical application of fluoride varnish |
32 |
32 |
$873.60 |
| D1110 |
Prophylaxis - adult |
14 |
14 |
$677.32 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
14 |
14 |
$365.12 |
| D1208 |
Topical application of fluoride, excluding varnish |
14 |
14 |
$354.90 |
| D0274 |
Bitewings - four radiographic images |
14 |
14 |
$219.34 |
| D0230 |
Intraoral - periapical each additional radiographic image |
16 |
16 |
$112.01 |
| D0220 |
Intraoral - periapical first radiographic image |
16 |
16 |
$105.76 |