| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
356 |
99 |
$24K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
160 |
160 |
$10K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
134 |
35 |
$7K |
| D9210 |
|
183 |
124 |
$7K |
| D0210 |
Intraoral - complete series of radiographic images |
98 |
98 |
$5K |
| D1320 |
|
126 |
126 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
223 |
59 |
$886.95 |
| D0120 |
Periodic oral evaluation - established patient |
18 |
17 |
$825.00 |
| D0350 |
|
52 |
13 |
$499.20 |
| D9430 |
|
12 |
12 |
$384.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
13 |
13 |
$178.00 |