| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
243 |
96 |
$16K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
216 |
216 |
$14K |
| D0350 |
|
848 |
199 |
$8K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
78 |
41 |
$4K |
| D0210 |
Intraoral - complete series of radiographic images |
84 |
84 |
$4K |
| D1110 |
Prophylaxis - adult |
42 |
42 |
$4K |
| D1206 |
Topical application of fluoride varnish |
182 |
181 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
369 |
84 |
$1K |
| D1120 |
Prophylaxis - child |
15 |
15 |
$787.50 |