| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
109 |
44 |
$7K |
| D0120 |
Periodic oral evaluation - established patient |
100 |
91 |
$6K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
59 |
59 |
$4K |
| D1208 |
Topical application of fluoride, excluding varnish |
222 |
212 |
$3K |
| D1110 |
Prophylaxis - adult |
27 |
27 |
$2K |
| D1120 |
Prophylaxis - child |
48 |
41 |
$2K |
| D0350 |
|
188 |
58 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
46 |
46 |
$2K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
24 |
15 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
359 |
125 |
$1K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
24 |
12 |
$1K |
| D0274 |
Bitewings - four radiographic images |
28 |
28 |
$464.40 |