| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
352 |
130 |
$18K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,446 |
684 |
$9K |
| D0220 |
Intraoral - periapical first radiographic image |
553 |
517 |
$6K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
115 |
113 |
$5K |
| D0350 |
|
521 |
205 |
$4K |
| D0274 |
Bitewings - four radiographic images |
163 |
163 |
$3K |
| D0120 |
Periodic oral evaluation - established patient |
79 |
78 |
$3K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
42 |
24 |
$3K |
| D1110 |
Prophylaxis - adult |
13 |
13 |
$1K |
| D1120 |
Prophylaxis - child |
38 |
38 |
$1K |
| D9430 |
|
34 |
32 |
$996.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
64 |
64 |
$623.00 |
| D0210 |
Intraoral - complete series of radiographic images |
12 |
12 |
$480.00 |