| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
642 |
237 |
$26K |
| D1110 |
Prophylaxis - adult |
891 |
891 |
$23K |
| D0210 |
Intraoral - complete series of radiographic images |
625 |
625 |
$18K |
| D0120 |
Periodic oral evaluation - established patient |
731 |
731 |
$13K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
258 |
258 |
$6K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
110 |
57 |
$4K |
| D0230 |
Intraoral - periapical each additional radiographic image |
391 |
384 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
642 |
638 |
$3K |
| D0274 |
Bitewings - four radiographic images |
270 |
270 |
$2K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
31 |
12 |
$1K |
| D1120 |
Prophylaxis - child |
27 |
27 |
$449.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
26 |
26 |
$275.00 |
| D0140 |
Limited oral evaluation - problem focused |
12 |
12 |
$261.00 |