| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
298 |
173 |
$20K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
316 |
316 |
$18K |
| D1110 |
Prophylaxis - adult |
219 |
219 |
$16K |
| D0274 |
Bitewings - four radiographic images |
389 |
389 |
$8K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
76 |
36 |
$4K |
| D1208 |
Topical application of fluoride, excluding varnish |
312 |
312 |
$4K |
| D0230 |
Intraoral - periapical each additional radiographic image |
557 |
292 |
$4K |
| D0350 |
|
216 |
104 |
$2K |
| D9430 |
|
36 |
36 |
$1K |
| D0120 |
Periodic oral evaluation - established patient |
25 |
25 |
$1K |
| D0210 |
Intraoral - complete series of radiographic images |
14 |
14 |
$560.00 |