| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
165 |
96 |
$8K |
| D1110 |
Prophylaxis - adult |
239 |
239 |
$8K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
214 |
214 |
$5K |
| D0210 |
Intraoral - complete series of radiographic images |
93 |
90 |
$5K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
90 |
55 |
$4K |
| D1206 |
Topical application of fluoride varnish |
313 |
313 |
$4K |
| D3320 |
|
14 |
13 |
$4K |
| D0274 |
Bitewings - four radiographic images |
193 |
193 |
$3K |
| D0120 |
Periodic oral evaluation - established patient |
155 |
155 |
$2K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
37 |
29 |
$2K |
| D2394 |
|
26 |
15 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
365 |
226 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
276 |
274 |
$1K |
| D0350 |
|
109 |
109 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
55 |
52 |
$1K |
| D2950 |
|
13 |
13 |
$995.02 |