| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
438 |
296 |
$22K |
| D1110 |
Prophylaxis - adult |
509 |
509 |
$18K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
400 |
400 |
$7K |
| D0210 |
Intraoral - complete series of radiographic images |
130 |
130 |
$5K |
| D0274 |
Bitewings - four radiographic images |
232 |
232 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
401 |
396 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
349 |
347 |
$3K |
| D0120 |
Periodic oral evaluation - established patient |
106 |
106 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
164 |
159 |
$1K |
| D1206 |
Topical application of fluoride varnish |
55 |
55 |
$990.00 |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
15 |
12 |
$950.40 |
| D1120 |
Prophylaxis - child |
12 |
12 |
$309.60 |