| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
85 |
25 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
396 |
270 |
$2K |
| D1110 |
Prophylaxis - adult |
61 |
58 |
$2K |
| D0120 |
Periodic oral evaluation - established patient |
78 |
66 |
$888.16 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
40 |
34 |
$790.50 |
| D0272 |
Bitewings - two radiographic images |
42 |
40 |
$370.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
44 |
42 |
$225.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
33 |
14 |
$145.00 |