| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
605 |
604 |
$40K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
580 |
290 |
$38K |
| D0350 |
|
2,088 |
573 |
$21K |
| D0210 |
Intraoral - complete series of radiographic images |
354 |
354 |
$17K |
| D4341 |
|
124 |
39 |
$9K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
148 |
81 |
$8K |
| D1120 |
Prophylaxis - child |
139 |
139 |
$7K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,722 |
363 |
$7K |
| D0120 |
Periodic oral evaluation - established patient |
75 |
75 |
$6K |
| D9430 |
|
149 |
132 |
$5K |
| D0274 |
Bitewings - four radiographic images |
183 |
183 |
$4K |
| D4910 |
|
39 |
39 |
$3K |
| D1208 |
Topical application of fluoride, excluding varnish |
107 |
107 |
$2K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
17 |
13 |
$1K |