| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
543 |
279 |
$36K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
298 |
297 |
$15K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
191 |
123 |
$15K |
| D1110 |
Prophylaxis - adult |
213 |
212 |
$14K |
| D0210 |
Intraoral - complete series of radiographic images |
231 |
231 |
$10K |
| D0350 |
|
735 |
311 |
$7K |
| D1120 |
Prophylaxis - child |
174 |
174 |
$5K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
79 |
43 |
$4K |
| D0120 |
Periodic oral evaluation - established patient |
125 |
124 |
$4K |
| D1206 |
Topical application of fluoride varnish |
406 |
404 |
$4K |
| D0230 |
Intraoral - periapical each additional radiographic image |
592 |
226 |
$2K |
| D0274 |
Bitewings - four radiographic images |
83 |
82 |
$2K |
| D9430 |
|
25 |
25 |
$700.00 |