| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
545 |
173 |
$18K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
257 |
132 |
$11K |
| D1110 |
Prophylaxis - adult |
316 |
300 |
$10K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
270 |
256 |
$7K |
| D1208 |
Topical application of fluoride, excluding varnish |
529 |
503 |
$6K |
| D0120 |
Periodic oral evaluation - established patient |
305 |
285 |
$6K |
| D0210 |
Intraoral - complete series of radiographic images |
146 |
141 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
493 |
435 |
$3K |
| D4341 |
|
122 |
37 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
128 |
119 |
$2K |
| D0274 |
Bitewings - four radiographic images |
187 |
179 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
544 |
257 |
$799.40 |