| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
213 |
93 |
$12K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
161 |
161 |
$10K |
| D0120 |
Periodic oral evaluation - established patient |
208 |
208 |
$9K |
| D9430 |
|
271 |
244 |
$9K |
| D1120 |
Prophylaxis - child |
202 |
202 |
$7K |
| D0220 |
Intraoral - periapical first radiographic image |
400 |
356 |
$5K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,162 |
214 |
$5K |
| D0210 |
Intraoral - complete series of radiographic images |
79 |
79 |
$4K |
| D0274 |
Bitewings - four radiographic images |
138 |
138 |
$3K |
| D1208 |
Topical application of fluoride, excluding varnish |
144 |
143 |
$1K |
| D4910 |
|
12 |
12 |
$847.00 |