| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
201 |
55 |
$19K |
| D1110 |
Prophylaxis - adult |
476 |
469 |
$18K |
| D0230 |
Intraoral - periapical each additional radiographic image |
601 |
406 |
$5K |
| D0120 |
Periodic oral evaluation - established patient |
291 |
289 |
$5K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
40 |
24 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
545 |
535 |
$5K |
| D1208 |
Topical application of fluoride, excluding varnish |
223 |
219 |
$4K |
| D0274 |
Bitewings - four radiographic images |
143 |
140 |
$4K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
53 |
53 |
$2K |
| D9630 |
|
43 |
40 |
$337.79 |
| D1206 |
Topical application of fluoride varnish |
16 |
16 |
$332.64 |