| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
89 |
43 |
$8K |
| D0210 |
Intraoral - complete series of radiographic images |
90 |
89 |
$6K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
151 |
149 |
$6K |
| D1120 |
Prophylaxis - child |
92 |
91 |
$4K |
| D1208 |
Topical application of fluoride, excluding varnish |
98 |
97 |
$2K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
26 |
12 |
$2K |
| D4355 |
|
16 |
16 |
$1K |
| D0120 |
Periodic oral evaluation - established patient |
42 |
42 |
$1K |
| D1110 |
Prophylaxis - adult |
13 |
13 |
$575.32 |
| D0220 |
Intraoral - periapical first radiographic image |
28 |
28 |
$401.00 |