| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,137 |
508 |
$76K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
900 |
900 |
$59K |
| D0210 |
Intraoral - complete series of radiographic images |
762 |
761 |
$36K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
652 |
268 |
$35K |
| D4910 |
|
173 |
173 |
$13K |
| D9430 |
|
390 |
380 |
$12K |
| D0120 |
Periodic oral evaluation - established patient |
154 |
153 |
$10K |
| D1208 |
Topical application of fluoride, excluding varnish |
521 |
521 |
$7K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,642 |
378 |
$7K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
58 |
38 |
$4K |
| D0350 |
|
470 |
194 |
$4K |
| D1120 |
Prophylaxis - child |
87 |
87 |
$3K |
| D0274 |
Bitewings - four radiographic images |
104 |
104 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
162 |
160 |
$2K |
| D1110 |
Prophylaxis - adult |
12 |
12 |
$1K |