| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
257 |
116 |
$13K |
| D1110 |
Prophylaxis - adult |
175 |
174 |
$5K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
175 |
175 |
$4K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
82 |
38 |
$4K |
| D0120 |
Periodic oral evaluation - established patient |
223 |
222 |
$4K |
| D0210 |
Intraoral - complete series of radiographic images |
96 |
95 |
$3K |
| D0274 |
Bitewings - four radiographic images |
173 |
171 |
$3K |
| D1206 |
Topical application of fluoride varnish |
217 |
213 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
371 |
190 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
282 |
267 |
$1K |
| D1120 |
Prophylaxis - child |
57 |
57 |
$1K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
16 |
12 |
$975.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
43 |
43 |
$645.00 |
| D0140 |
Limited oral evaluation - problem focused |
13 |
13 |
$293.54 |
| D0272 |
Bitewings - two radiographic images |
12 |
12 |
$120.00 |
| D0350 |
|
23 |
23 |
$12.31 |