| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
150 |
84 |
$11K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
293 |
293 |
$10K |
| D1110 |
Prophylaxis - adult |
193 |
193 |
$8K |
| D4346 |
|
69 |
69 |
$8K |
| D0274 |
Bitewings - four radiographic images |
272 |
272 |
$8K |
| D0210 |
Intraoral - complete series of radiographic images |
101 |
97 |
$6K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
58 |
30 |
$3K |
| D1208 |
Topical application of fluoride, excluding varnish |
136 |
136 |
$2K |
| D1120 |
Prophylaxis - child |
69 |
69 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
167 |
166 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
28 |
28 |
$832.78 |
| D0230 |
Intraoral - periapical each additional radiographic image |
38 |
31 |
$498.19 |
| D0120 |
Periodic oral evaluation - established patient |
12 |
12 |
$246.39 |
| D1206 |
Topical application of fluoride varnish |
14 |
14 |
$236.75 |