| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
192 |
97 |
$23K |
| D1110 |
Prophylaxis - adult |
285 |
284 |
$15K |
| D0120 |
Periodic oral evaluation - established patient |
385 |
385 |
$10K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
194 |
194 |
$9K |
| D0210 |
Intraoral - complete series of radiographic images |
79 |
78 |
$5K |
| D1120 |
Prophylaxis - child |
119 |
119 |
$5K |
| D1206 |
Topical application of fluoride varnish |
134 |
134 |
$4K |
| D0274 |
Bitewings - four radiographic images |
89 |
89 |
$3K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
31 |
15 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
17 |
12 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
78 |
78 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
71 |
67 |
$720.00 |
| D0140 |
Limited oral evaluation - problem focused |
12 |
12 |
$529.60 |
| D1208 |
Topical application of fluoride, excluding varnish |
12 |
12 |
$300.90 |