| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
612 |
142 |
$52K |
| D1110 |
Prophylaxis - adult |
216 |
216 |
$8K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
51 |
27 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
364 |
330 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
258 |
219 |
$2K |
| D0120 |
Periodic oral evaluation - established patient |
187 |
187 |
$2K |
| D0274 |
Bitewings - four radiographic images |
62 |
62 |
$2K |
| D4355 |
|
13 |
13 |
$1K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
28 |
24 |
$688.82 |
| D1208 |
Topical application of fluoride, excluding varnish |
13 |
13 |
$270.27 |
| D1999 |
|
14 |
14 |
$0.00 |