| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
107 |
47 |
$6K |
| D9430 |
|
92 |
77 |
$3K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
25 |
14 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
155 |
133 |
$2K |
| D1120 |
Prophylaxis - child |
51 |
51 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
187 |
43 |
$606.00 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
17 |
17 |
$400.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
37 |
37 |
$332.00 |
| D0120 |
Periodic oral evaluation - established patient |
12 |
12 |
$252.00 |