| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
120 |
38 |
$8K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
83 |
39 |
$7K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
51 |
26 |
$6K |
| D0210 |
Intraoral - complete series of radiographic images |
159 |
159 |
$5K |
| D4355 |
|
105 |
105 |
$4K |
| D0120 |
Periodic oral evaluation - established patient |
145 |
144 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
107 |
106 |
$2K |
| D1120 |
Prophylaxis - child |
51 |
49 |
$2K |
| D1110 |
Prophylaxis - adult |
12 |
12 |
$431.50 |
| D1206 |
Topical application of fluoride varnish |
13 |
13 |
$325.00 |
| D0274 |
Bitewings - four radiographic images |
14 |
14 |
$219.26 |
| D0220 |
Intraoral - periapical first radiographic image |
13 |
13 |
$131.15 |