| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
203 |
104 |
$26K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
291 |
286 |
$16K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
93 |
51 |
$16K |
| D2750 |
|
20 |
13 |
$10K |
| D1110 |
Prophylaxis - adult |
134 |
134 |
$9K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
67 |
27 |
$7K |
| D0210 |
Intraoral - complete series of radiographic images |
44 |
44 |
$3K |
| D1208 |
Topical application of fluoride, excluding varnish |
106 |
101 |
$2K |
| D2950 |
|
22 |
13 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
120 |
117 |
$1K |
| D0120 |
Periodic oral evaluation - established patient |
31 |
31 |
$986.10 |
| D0230 |
Intraoral - periapical each additional radiographic image |
29 |
26 |
$308.32 |
| D0274 |
Bitewings - four radiographic images |
12 |
12 |
$288.84 |