| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
387 |
193 |
$24K |
| D1110 |
Prophylaxis - adult |
509 |
509 |
$14K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
351 |
350 |
$11K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
100 |
51 |
$8K |
| D0274 |
Bitewings - four radiographic images |
365 |
363 |
$7K |
| D0220 |
Intraoral - periapical first radiographic image |
727 |
697 |
$5K |
| D0230 |
Intraoral - periapical each additional radiographic image |
592 |
474 |
$5K |
| D1208 |
Topical application of fluoride, excluding varnish |
193 |
193 |
$5K |
| D0120 |
Periodic oral evaluation - established patient |
421 |
419 |
$4K |
| D1120 |
Prophylaxis - child |
105 |
105 |
$3K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
13 |
12 |
$1K |
| D9994 |
|
12 |
12 |
$99.36 |
| D1206 |
Topical application of fluoride varnish |
13 |
13 |
$0.00 |
| D0140 |
Limited oral evaluation - problem focused |
12 |
12 |
$0.00 |