| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
928 |
486 |
$62K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
905 |
504 |
$49K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
421 |
421 |
$28K |
| D1120 |
Prophylaxis - child |
248 |
248 |
$13K |
| D1110 |
Prophylaxis - adult |
130 |
130 |
$12K |
| D0120 |
Periodic oral evaluation - established patient |
134 |
134 |
$11K |
| D1208 |
Topical application of fluoride, excluding varnish |
592 |
592 |
$9K |
| D0274 |
Bitewings - four radiographic images |
295 |
295 |
$6K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,469 |
485 |
$6K |
| D0210 |
Intraoral - complete series of radiographic images |
79 |
79 |
$4K |
| D9430 |
|
12 |
12 |
$384.00 |