| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
574 |
167 |
$36K |
| D1110 |
Prophylaxis - adult |
840 |
832 |
$27K |
| D0274 |
Bitewings - four radiographic images |
623 |
615 |
$13K |
| D0210 |
Intraoral - complete series of radiographic images |
284 |
278 |
$11K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
368 |
361 |
$11K |
| D0120 |
Periodic oral evaluation - established patient |
726 |
722 |
$9K |
| D9994 |
|
1,190 |
1,171 |
$7K |
| D1208 |
Topical application of fluoride, excluding varnish |
461 |
460 |
$6K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
58 |
39 |
$6K |
| D0220 |
Intraoral - periapical first radiographic image |
190 |
178 |
$2K |
| D9992 |
|
167 |
166 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
51 |
48 |
$1K |
| D0330 |
Panoramic radiographic image |
13 |
13 |
$701.87 |
| D1120 |
Prophylaxis - child |
68 |
68 |
$402.24 |
| D0230 |
Intraoral - periapical each additional radiographic image |
21 |
12 |
$305.13 |
| D9920 |
|
12 |
12 |
$0.00 |