| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
93 |
48 |
$5K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
87 |
40 |
$4K |
| D0210 |
Intraoral - complete series of radiographic images |
84 |
73 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
121 |
117 |
$2K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
39 |
26 |
$2K |
| D1110 |
Prophylaxis - adult |
75 |
69 |
$2K |
| D0120 |
Periodic oral evaluation - established patient |
86 |
83 |
$1K |
| D0274 |
Bitewings - four radiographic images |
71 |
71 |
$1K |
| D1206 |
Topical application of fluoride varnish |
30 |
30 |
$435.00 |
| D0220 |
Intraoral - periapical first radiographic image |
82 |
77 |
$295.00 |
| D1120 |
Prophylaxis - child |
13 |
13 |
$220.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
39 |
29 |
$135.00 |