| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
318 |
168 |
$42K |
| D1110 |
Prophylaxis - adult |
596 |
587 |
$38K |
| D2750 |
|
50 |
39 |
$23K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
367 |
350 |
$19K |
| D1206 |
Topical application of fluoride varnish |
686 |
673 |
$17K |
| D0210 |
Intraoral - complete series of radiographic images |
268 |
259 |
$14K |
| D0120 |
Periodic oral evaluation - established patient |
427 |
427 |
$14K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
82 |
58 |
$13K |
| D0140 |
Limited oral evaluation - problem focused |
180 |
162 |
$8K |
| D0220 |
Intraoral - periapical first radiographic image |
402 |
376 |
$4K |
| D2335 |
|
20 |
12 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
22 |
13 |
$2K |
| D4355 |
|
13 |
13 |
$1K |
| D0274 |
Bitewings - four radiographic images |
48 |
41 |
$986.87 |
| D0230 |
Intraoral - periapical each additional radiographic image |
141 |
134 |
$984.00 |