| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
398 |
178 |
$55K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
291 |
110 |
$50K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
451 |
451 |
$25K |
| D1110 |
Prophylaxis - adult |
241 |
241 |
$16K |
| D0210 |
Intraoral - complete series of radiographic images |
275 |
275 |
$16K |
| D0140 |
Limited oral evaluation - problem focused |
172 |
170 |
$8K |
| D1206 |
Topical application of fluoride varnish |
239 |
237 |
$6K |
| D0220 |
Intraoral - periapical first radiographic image |
299 |
295 |
$4K |
| D0120 |
Periodic oral evaluation - established patient |
88 |
88 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
26 |
14 |
$3K |
| D1120 |
Prophylaxis - child |
29 |
29 |
$1K |
| D0274 |
Bitewings - four radiographic images |
25 |
25 |
$601.75 |
| D0330 |
Panoramic radiographic image |
12 |
12 |
$413.55 |
| D0230 |
Intraoral - periapical each additional radiographic image |
29 |
29 |
$196.80 |