| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
531 |
177 |
$74K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
243 |
113 |
$26K |
| D1110 |
Prophylaxis - adult |
274 |
274 |
$18K |
| D0120 |
Periodic oral evaluation - established patient |
247 |
247 |
$8K |
| D1206 |
Topical application of fluoride varnish |
278 |
278 |
$7K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
21 |
13 |
$4K |
| D0274 |
Bitewings - four radiographic images |
151 |
151 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
290 |
275 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
56 |
56 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
56 |
56 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
227 |
224 |
$1K |
| D1330 |
|
25 |
25 |
$180.00 |