| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
182 |
81 |
$25K |
| D0140 |
Limited oral evaluation - problem focused |
281 |
254 |
$16K |
| D1110 |
Prophylaxis - adult |
250 |
190 |
$15K |
| D0120 |
Periodic oral evaluation - established patient |
355 |
287 |
$14K |
| D1206 |
Topical application of fluoride varnish |
419 |
363 |
$10K |
| D1120 |
Prophylaxis - child |
96 |
89 |
$6K |
| D0220 |
Intraoral - periapical first radiographic image |
214 |
200 |
$5K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
25 |
13 |
$5K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
72 |
51 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
30 |
14 |
$3K |
| D0274 |
Bitewings - four radiographic images |
55 |
37 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
14 |
13 |
$1K |
| D1999 |
|
212 |
157 |
$0.00 |