| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
450 |
194 |
$28K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
345 |
176 |
$26K |
| D0210 |
Intraoral - complete series of radiographic images |
322 |
300 |
$22K |
| D1110 |
Prophylaxis - adult |
392 |
368 |
$21K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
488 |
457 |
$21K |
| D1120 |
Prophylaxis - child |
50 |
46 |
$2K |
| D1206 |
Topical application of fluoride varnish |
88 |
77 |
$2K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
20 |
14 |
$2K |
| D0120 |
Periodic oral evaluation - established patient |
72 |
71 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
44 |
39 |
$747.00 |
| D0274 |
Bitewings - four radiographic images |
13 |
13 |
$532.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
18 |
14 |
$269.00 |