| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2750 |
|
37 |
24 |
$24K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
133 |
60 |
$20K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
103 |
60 |
$13K |
| D0120 |
Periodic oral evaluation - established patient |
396 |
396 |
$11K |
| D2950 |
|
36 |
24 |
$7K |
| D2335 |
|
42 |
13 |
$6K |
| D1110 |
Prophylaxis - adult |
101 |
101 |
$5K |
| D2394 |
|
29 |
12 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
244 |
244 |
$4K |
| D1120 |
Prophylaxis - child |
89 |
89 |
$4K |
| D2332 |
|
23 |
14 |
$3K |
| D1208 |
Topical application of fluoride, excluding varnish |
132 |
132 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
40 |
40 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
179 |
167 |
$2K |
| D0274 |
Bitewings - four radiographic images |
18 |
18 |
$679.00 |