| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
70 |
43 |
$10K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
36 |
27 |
$4K |
| D0120 |
Periodic oral evaluation - established patient |
158 |
158 |
$3K |
| D1110 |
Prophylaxis - adult |
83 |
83 |
$3K |
| D0210 |
Intraoral - complete series of radiographic images |
42 |
42 |
$3K |
| D1120 |
Prophylaxis - child |
93 |
93 |
$3K |
| D1206 |
Topical application of fluoride varnish |
119 |
119 |
$2K |
| D0180 |
|
42 |
42 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
133 |
132 |
$2K |
| D0274 |
Bitewings - four radiographic images |
50 |
50 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
78 |
78 |
$949.03 |
| D0272 |
Bitewings - two radiographic images |
35 |
35 |
$720.92 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
15 |
15 |
$560.25 |
| D0140 |
Limited oral evaluation - problem focused |
12 |
12 |
$389.88 |