| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,496 |
381 |
$70K |
| D1110 |
Prophylaxis - adult |
769 |
760 |
$18K |
| D0120 |
Periodic oral evaluation - established patient |
526 |
522 |
$12K |
| D2332 |
|
153 |
54 |
$9K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
172 |
68 |
$9K |
| D0274 |
Bitewings - four radiographic images |
742 |
735 |
$8K |
| D0220 |
Intraoral - periapical first radiographic image |
1,188 |
1,171 |
$5K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
191 |
190 |
$4K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,216 |
1,023 |
$4K |
| D1120 |
Prophylaxis - child |
13 |
12 |
$242.53 |
| D1206 |
Topical application of fluoride varnish |
12 |
12 |
$198.48 |
| D0603 |
|
17 |
17 |
$63.00 |