| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
72 |
41 |
$10K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
49 |
32 |
$8K |
| D1110 |
Prophylaxis - adult |
169 |
164 |
$7K |
| D0120 |
Periodic oral evaluation - established patient |
254 |
244 |
$6K |
| D2394 |
|
20 |
14 |
$4K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
90 |
86 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
181 |
171 |
$2K |
| D0274 |
Bitewings - four radiographic images |
42 |
42 |
$1K |
| D0210 |
Intraoral - complete series of radiographic images |
15 |
15 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
27 |
26 |
$914.58 |
| D0230 |
Intraoral - periapical each additional radiographic image |
39 |
39 |
$904.56 |
| D1206 |
Topical application of fluoride varnish |
37 |
36 |
$654.84 |