| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
226 |
113 |
$22K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
105 |
54 |
$12K |
| D4355 |
|
161 |
158 |
$10K |
| D1110 |
Prophylaxis - adult |
209 |
207 |
$7K |
| D0210 |
Intraoral - complete series of radiographic images |
107 |
105 |
$7K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
159 |
155 |
$6K |
| D0120 |
Periodic oral evaluation - established patient |
277 |
271 |
$6K |
| D0220 |
Intraoral - periapical first radiographic image |
304 |
292 |
$4K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
36 |
24 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
65 |
64 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
194 |
118 |
$2K |
| D1206 |
Topical application of fluoride varnish |
60 |
59 |
$884.50 |
| D0274 |
Bitewings - four radiographic images |
13 |
13 |
$332.50 |