| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
279 |
149 |
$19K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
253 |
253 |
$16K |
| D4910 |
|
101 |
101 |
$8K |
| D0120 |
Periodic oral evaluation - established patient |
99 |
99 |
$4K |
| D0350 |
|
423 |
194 |
$4K |
| D0210 |
Intraoral - complete series of radiographic images |
79 |
79 |
$3K |
| D1208 |
Topical application of fluoride, excluding varnish |
240 |
240 |
$3K |
| D0274 |
Bitewings - four radiographic images |
98 |
98 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
501 |
212 |
$2K |
| D1120 |
Prophylaxis - child |
63 |
63 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
20 |
14 |
$1K |
| D1206 |
Topical application of fluoride varnish |
13 |
13 |
$192.00 |