| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
132 |
57 |
$15K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
271 |
271 |
$11K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
85 |
41 |
$11K |
| D1110 |
Prophylaxis - adult |
224 |
224 |
$11K |
| D0210 |
Intraoral - complete series of radiographic images |
146 |
146 |
$10K |
| D0220 |
Intraoral - periapical first radiographic image |
196 |
177 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
26 |
13 |
$3K |
| D1206 |
Topical application of fluoride varnish |
80 |
80 |
$2K |
| D1120 |
Prophylaxis - child |
44 |
43 |
$2K |
| D0120 |
Periodic oral evaluation - established patient |
58 |
58 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
63 |
44 |
$607.50 |