| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
949 |
202 |
$91K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
377 |
132 |
$48K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
273 |
87 |
$42K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
248 |
248 |
$11K |
| D1110 |
Prophylaxis - adult |
138 |
138 |
$7K |
| D1120 |
Prophylaxis - child |
140 |
140 |
$6K |
| D0220 |
Intraoral - periapical first radiographic image |
319 |
317 |
$5K |
| D1208 |
Topical application of fluoride, excluding varnish |
162 |
162 |
$4K |
| D0230 |
Intraoral - periapical each additional radiographic image |
347 |
304 |
$3K |
| D0272 |
Bitewings - two radiographic images |
76 |
76 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
13 |
13 |
$1K |
| D0120 |
Periodic oral evaluation - established patient |
37 |
37 |
$1K |