| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
561 |
139 |
$31K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
249 |
87 |
$21K |
| D2335 |
|
205 |
48 |
$17K |
| D1110 |
Prophylaxis - adult |
227 |
227 |
$10K |
| D2394 |
|
92 |
33 |
$8K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
111 |
52 |
$8K |
| D0120 |
Periodic oral evaluation - established patient |
305 |
305 |
$8K |
| D1120 |
Prophylaxis - child |
80 |
80 |
$4K |
| D0274 |
Bitewings - four radiographic images |
207 |
207 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
86 |
86 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
68 |
68 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
185 |
181 |
$941.00 |
| D0210 |
Intraoral - complete series of radiographic images |
18 |
18 |
$810.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
140 |
138 |
$624.00 |
| D0140 |
Limited oral evaluation - problem focused |
12 |
12 |
$540.00 |