| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
211 |
109 |
$12K |
| D0210 |
Intraoral - complete series of radiographic images |
200 |
200 |
$8K |
| D1110 |
Prophylaxis - adult |
196 |
196 |
$7K |
| D0140 |
Limited oral evaluation - problem focused |
118 |
115 |
$6K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
273 |
273 |
$5K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
54 |
29 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
175 |
170 |
$1K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
24 |
13 |
$1K |
| D1206 |
Topical application of fluoride varnish |
47 |
47 |
$828.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
92 |
67 |
$696.00 |
| D0274 |
Bitewings - four radiographic images |
25 |
25 |
$560.00 |