| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
410 |
257 |
$28K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
314 |
210 |
$28K |
| D1110 |
Prophylaxis - adult |
511 |
511 |
$25K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
224 |
224 |
$9K |
| D0120 |
Periodic oral evaluation - established patient |
379 |
379 |
$8K |
| D0274 |
Bitewings - four radiographic images |
248 |
248 |
$7K |
| D0140 |
Limited oral evaluation - problem focused |
145 |
145 |
$5K |
| D1206 |
Topical application of fluoride varnish |
284 |
284 |
$5K |
| D1120 |
Prophylaxis - child |
52 |
52 |
$2K |
| D2331 |
|
19 |
12 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
28 |
28 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
76 |
75 |
$961.48 |