| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
327 |
181 |
$43K |
| D0220 |
Intraoral - periapical first radiographic image |
703 |
586 |
$12K |
| D0140 |
Limited oral evaluation - problem focused |
275 |
264 |
$12K |
| D0120 |
Periodic oral evaluation - established patient |
352 |
352 |
$10K |
| D1110 |
Prophylaxis - adult |
106 |
106 |
$6K |
| D0230 |
Intraoral - periapical each additional radiographic image |
555 |
303 |
$5K |
| D1206 |
Topical application of fluoride varnish |
114 |
113 |
$3K |
| D0274 |
Bitewings - four radiographic images |
74 |
74 |
$3K |
| D1120 |
Prophylaxis - child |
60 |
60 |
$3K |
| D2950 |
|
15 |
12 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
32 |
32 |
$2K |