| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
616 |
248 |
$45K |
| D1110 |
Prophylaxis - adult |
559 |
526 |
$21K |
| D0140 |
Limited oral evaluation - problem focused |
741 |
577 |
$12K |
| D0220 |
Intraoral - periapical first radiographic image |
1,296 |
934 |
$10K |
| D0120 |
Periodic oral evaluation - established patient |
374 |
359 |
$6K |
| D1208 |
Topical application of fluoride, excluding varnish |
305 |
301 |
$6K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
45 |
24 |
$4K |
| D0274 |
Bitewings - four radiographic images |
108 |
98 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
57 |
45 |
$1K |
| D0330 |
Panoramic radiographic image |
34 |
26 |
$1K |
| D1120 |
Prophylaxis - child |
25 |
25 |
$838.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
19 |
12 |
$212.42 |
| D1999 |
|
32 |
14 |
$0.00 |