| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
226 |
111 |
$20K |
| D0140 |
Limited oral evaluation - problem focused |
537 |
528 |
$16K |
| D0210 |
Intraoral - complete series of radiographic images |
201 |
199 |
$8K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
115 |
66 |
$8K |
| D0274 |
Bitewings - four radiographic images |
173 |
172 |
$6K |
| D0230 |
Intraoral - periapical each additional radiographic image |
357 |
179 |
$4K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
42 |
25 |
$4K |
| D1120 |
Prophylaxis - child |
73 |
73 |
$3K |
| D1110 |
Prophylaxis - adult |
105 |
102 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
231 |
229 |
$3K |
| D1208 |
Topical application of fluoride, excluding varnish |
60 |
60 |
$2K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
21 |
17 |
$1K |