| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
174 |
115 |
$21K |
| D1110 |
Prophylaxis - adult |
334 |
334 |
$16K |
| D1120 |
Prophylaxis - child |
447 |
447 |
$15K |
| D0120 |
Periodic oral evaluation - established patient |
576 |
576 |
$14K |
| D1206 |
Topical application of fluoride varnish |
579 |
579 |
$10K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
39 |
29 |
$6K |
| D0210 |
Intraoral - complete series of radiographic images |
91 |
91 |
$6K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
122 |
122 |
$4K |
| D0274 |
Bitewings - four radiographic images |
115 |
115 |
$4K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
21 |
12 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
99 |
98 |
$2K |
| D0272 |
Bitewings - two radiographic images |
14 |
14 |
$299.00 |