| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
320 |
172 |
$38K |
| D0120 |
Periodic oral evaluation - established patient |
805 |
804 |
$20K |
| D1120 |
Prophylaxis - child |
532 |
532 |
$19K |
| D1206 |
Topical application of fluoride varnish |
677 |
676 |
$15K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
286 |
286 |
$13K |
| D1110 |
Prophylaxis - adult |
149 |
149 |
$8K |
| D0210 |
Intraoral - complete series of radiographic images |
84 |
84 |
$6K |
| D0220 |
Intraoral - periapical first radiographic image |
408 |
401 |
$6K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
23 |
15 |
$4K |
| D2950 |
|
14 |
12 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
160 |
154 |
$1K |
| D0274 |
Bitewings - four radiographic images |
43 |
43 |
$1K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
18 |
13 |
$1K |
| D1208 |
Topical application of fluoride, excluding varnish |
15 |
15 |
$375.00 |
| D0272 |
Bitewings - two radiographic images |
14 |
14 |
$319.75 |
| D1999 |
|
54 |
54 |
$0.00 |