| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
617 |
313 |
$60K |
| D1110 |
Prophylaxis - adult |
788 |
637 |
$30K |
| D5214 |
|
15 |
15 |
$15K |
| D5213 |
|
16 |
15 |
$14K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
73 |
59 |
$12K |
| D0210 |
Intraoral - complete series of radiographic images |
193 |
176 |
$11K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
280 |
239 |
$8K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
101 |
70 |
$6K |
| D1208 |
Topical application of fluoride, excluding varnish |
424 |
342 |
$6K |
| D0120 |
Periodic oral evaluation - established patient |
348 |
246 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
135 |
98 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
70 |
57 |
$2K |
| D1206 |
Topical application of fluoride varnish |
38 |
38 |
$738.36 |