| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
245 |
138 |
$13K |
| D1110 |
Prophylaxis - adult |
388 |
388 |
$12K |
| D2750 |
|
19 |
12 |
$10K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
304 |
304 |
$9K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
151 |
82 |
$8K |
| D0210 |
Intraoral - complete series of radiographic images |
173 |
173 |
$7K |
| D0120 |
Periodic oral evaluation - established patient |
218 |
218 |
$5K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
63 |
25 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
66 |
63 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
319 |
307 |
$1K |
| D2950 |
|
17 |
14 |
$1K |
| D2394 |
|
16 |
12 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
102 |
102 |
$696.75 |
| D1120 |
Prophylaxis - child |
13 |
13 |
$406.25 |
| D0274 |
Bitewings - four radiographic images |
24 |
24 |
$390.00 |