| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
474 |
303 |
$65K |
| D1110 |
Prophylaxis - adult |
886 |
881 |
$58K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
650 |
639 |
$36K |
| D2750 |
|
59 |
40 |
$29K |
| D0210 |
Intraoral - complete series of radiographic images |
501 |
492 |
$28K |
| D0120 |
Periodic oral evaluation - established patient |
532 |
529 |
$17K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
149 |
90 |
$16K |
| D0140 |
Limited oral evaluation - problem focused |
268 |
263 |
$13K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
34 |
27 |
$6K |
| D0220 |
Intraoral - periapical first radiographic image |
401 |
394 |
$5K |
| D2950 |
|
42 |
27 |
$4K |
| D0274 |
Bitewings - four radiographic images |
124 |
124 |
$3K |
| D1206 |
Topical application of fluoride varnish |
12 |
12 |
$299.04 |
| D0270 |
|
12 |
12 |
$108.00 |