| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
80 |
47 |
$4K |
| D0120 |
Periodic oral evaluation - established patient |
151 |
148 |
$4K |
| D1110 |
Prophylaxis - adult |
94 |
92 |
$4K |
| D1208 |
Topical application of fluoride, excluding varnish |
205 |
201 |
$4K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
61 |
40 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
62 |
53 |
$2K |
| D0274 |
Bitewings - four radiographic images |
103 |
101 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
126 |
117 |
$1K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
28 |
27 |
$948.00 |
| D1120 |
Prophylaxis - child |
33 |
33 |
$930.00 |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
19 |
13 |
$871.00 |
| D4910 |
|
13 |
13 |
$744.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
12 |
12 |
$48.00 |