| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
624 |
391 |
$29K |
| D0120 |
Periodic oral evaluation - established patient |
1,139 |
1,139 |
$26K |
| D1110 |
Prophylaxis - adult |
1,094 |
1,094 |
$25K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
287 |
176 |
$15K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
366 |
258 |
$15K |
| D1120 |
Prophylaxis - child |
353 |
353 |
$10K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
341 |
341 |
$8K |
| D0140 |
Limited oral evaluation - problem focused |
315 |
305 |
$7K |
| D0274 |
Bitewings - four radiographic images |
480 |
480 |
$7K |
| D2750 |
|
14 |
12 |
$6K |
| D0210 |
Intraoral - complete series of radiographic images |
179 |
179 |
$6K |
| D1206 |
Topical application of fluoride varnish |
259 |
259 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
734 |
706 |
$3K |
| D2335 |
|
25 |
12 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
106 |
105 |
$603.75 |