| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
172 |
73 |
$14K |
| D0210 |
Intraoral - complete series of radiographic images |
175 |
164 |
$10K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
249 |
238 |
$7K |
| D1110 |
Prophylaxis - adult |
104 |
102 |
$4K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
30 |
13 |
$3K |
| D1208 |
Topical application of fluoride, excluding varnish |
27 |
27 |
$662.32 |
| D0140 |
Limited oral evaluation - problem focused |
12 |
12 |
$292.80 |
| D0274 |
Bitewings - four radiographic images |
12 |
12 |
$271.67 |
| D0220 |
Intraoral - periapical first radiographic image |
13 |
13 |
$166.53 |