| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
204 |
204 |
$13K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
160 |
93 |
$10K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
119 |
73 |
$9K |
| D1110 |
Prophylaxis - adult |
92 |
92 |
$8K |
| D0210 |
Intraoral - complete series of radiographic images |
158 |
158 |
$8K |
| D0350 |
|
812 |
173 |
$8K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
45 |
26 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
193 |
166 |
$2K |
| D1206 |
Topical application of fluoride varnish |
99 |
99 |
$2K |
| D1120 |
Prophylaxis - child |
17 |
17 |
$892.50 |
| D0230 |
Intraoral - periapical each additional radiographic image |
180 |
113 |
$682.46 |
| D1208 |
Topical application of fluoride, excluding varnish |
31 |
31 |
$418.75 |