| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
184 |
88 |
$25K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
192 |
186 |
$7K |
| D1110 |
Prophylaxis - adult |
142 |
138 |
$6K |
| D0210 |
Intraoral - complete series of radiographic images |
53 |
51 |
$4K |
| D0120 |
Periodic oral evaluation - established patient |
116 |
113 |
$3K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
14 |
12 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
105 |
100 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
24 |
24 |
$779.76 |
| D0274 |
Bitewings - four radiographic images |
14 |
14 |
$393.96 |
| D0230 |
Intraoral - periapical each additional radiographic image |
14 |
14 |
$309.40 |
| D1206 |
Topical application of fluoride varnish |
12 |
12 |
$194.88 |