| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
266 |
190 |
$23K |
| D1120 |
Prophylaxis - child |
645 |
643 |
$23K |
| D0120 |
Periodic oral evaluation - established patient |
820 |
817 |
$20K |
| D1110 |
Prophylaxis - adult |
298 |
297 |
$14K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
113 |
81 |
$13K |
| D1208 |
Topical application of fluoride, excluding varnish |
528 |
526 |
$11K |
| D0220 |
Intraoral - periapical first radiographic image |
518 |
507 |
$8K |
| D1206 |
Topical application of fluoride varnish |
277 |
277 |
$6K |
| D0140 |
Limited oral evaluation - problem focused |
151 |
150 |
$6K |
| D0272 |
Bitewings - two radiographic images |
242 |
241 |
$6K |
| D0230 |
Intraoral - periapical each additional radiographic image |
369 |
362 |
$3K |
| D0330 |
Panoramic radiographic image |
33 |
33 |
$2K |
| D0274 |
Bitewings - four radiographic images |
41 |
40 |
$1K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
12 |
12 |
$502.00 |