| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
723 |
147 |
$55K |
| D1110 |
Prophylaxis - adult |
338 |
336 |
$17K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
140 |
58 |
$15K |
| D0120 |
Periodic oral evaluation - established patient |
565 |
561 |
$15K |
| D2950 |
|
81 |
59 |
$14K |
| D1120 |
Prophylaxis - child |
354 |
353 |
$14K |
| D1208 |
Topical application of fluoride, excluding varnish |
463 |
459 |
$11K |
| D2750 |
|
15 |
12 |
$10K |
| D0220 |
Intraoral - periapical first radiographic image |
604 |
541 |
$9K |
| D0210 |
Intraoral - complete series of radiographic images |
142 |
140 |
$9K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
139 |
136 |
$5K |
| D4355 |
|
25 |
25 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
287 |
232 |
$2K |
| D0274 |
Bitewings - four radiographic images |
24 |
24 |
$798.00 |
| D0272 |
Bitewings - two radiographic images |
12 |
12 |
$225.00 |