| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
203 |
114 |
$17K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
131 |
72 |
$14K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
239 |
236 |
$11K |
| D1110 |
Prophylaxis - adult |
130 |
129 |
$8K |
| D4341 |
|
160 |
71 |
$7K |
| D0210 |
Intraoral - complete series of radiographic images |
101 |
100 |
$6K |
| D0140 |
Limited oral evaluation - problem focused |
162 |
147 |
$5K |
| D1208 |
Topical application of fluoride, excluding varnish |
123 |
123 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
201 |
187 |
$2K |
| D1206 |
Topical application of fluoride varnish |
59 |
59 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
235 |
158 |
$772.05 |
| D0120 |
Periodic oral evaluation - established patient |
15 |
15 |
$502.29 |
| D0274 |
Bitewings - four radiographic images |
31 |
31 |
$400.23 |