| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
258 |
140 |
$17K |
| D1110 |
Prophylaxis - adult |
359 |
357 |
$16K |
| D0120 |
Periodic oral evaluation - established patient |
336 |
334 |
$8K |
| D1206 |
Topical application of fluoride varnish |
267 |
266 |
$7K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
73 |
59 |
$6K |
| D0274 |
Bitewings - four radiographic images |
233 |
230 |
$3K |
| D1208 |
Topical application of fluoride, excluding varnish |
80 |
79 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
350 |
347 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
288 |
285 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
27 |
27 |
$1K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
17 |
12 |
$825.00 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
25 |
25 |
$625.00 |
| D0140 |
Limited oral evaluation - problem focused |
12 |
12 |
$540.00 |
| D0603 |
|
19 |
16 |
$30.00 |