| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
128 |
55 |
$9K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
112 |
112 |
$7K |
| D9430 |
|
170 |
156 |
$5K |
| D0210 |
Intraoral - complete series of radiographic images |
105 |
105 |
$5K |
| D0350 |
|
414 |
158 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
33 |
16 |
$2K |
| D4910 |
|
24 |
24 |
$2K |
| D4342 |
|
41 |
15 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
415 |
220 |
$2K |
| D1110 |
Prophylaxis - adult |
12 |
12 |
$1K |
| D1208 |
Topical application of fluoride, excluding varnish |
72 |
72 |
$834.00 |
| D0270 |
|
152 |
140 |
$741.25 |
| D1120 |
Prophylaxis - child |
13 |
13 |
$390.00 |