| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
566 |
153 |
$60K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
379 |
162 |
$52K |
| D1110 |
Prophylaxis - adult |
300 |
300 |
$20K |
| D0120 |
Periodic oral evaluation - established patient |
424 |
424 |
$13K |
| D0140 |
Limited oral evaluation - problem focused |
260 |
255 |
$12K |
| D1120 |
Prophylaxis - child |
190 |
190 |
$9K |
| D1206 |
Topical application of fluoride varnish |
333 |
333 |
$9K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
18 |
13 |
$3K |
| D3120 |
|
82 |
42 |
$3K |
| D0210 |
Intraoral - complete series of radiographic images |
41 |
41 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
196 |
194 |
$2K |
| D0274 |
Bitewings - four radiographic images |
52 |
52 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
106 |
106 |
$839.68 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
14 |
14 |
$788.76 |