| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
167 |
72 |
$18K |
| D1110 |
Prophylaxis - adult |
265 |
265 |
$17K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
83 |
48 |
$11K |
| D1208 |
Topical application of fluoride, excluding varnish |
329 |
329 |
$8K |
| D0120 |
Periodic oral evaluation - established patient |
238 |
238 |
$7K |
| D0330 |
Panoramic radiographic image |
100 |
100 |
$5K |
| D0274 |
Bitewings - four radiographic images |
190 |
190 |
$4K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
62 |
62 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
254 |
251 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
229 |
227 |
$1K |
| D1120 |
Prophylaxis - child |
22 |
22 |
$1K |
| D3120 |
|
22 |
17 |
$770.00 |
| D1330 |
|
92 |
92 |
$662.40 |