| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
116 |
77 |
$11K |
| D1110 |
Prophylaxis - adult |
286 |
282 |
$10K |
| D0120 |
Periodic oral evaluation - established patient |
350 |
346 |
$8K |
| D0274 |
Bitewings - four radiographic images |
198 |
196 |
$6K |
| D0220 |
Intraoral - periapical first radiographic image |
310 |
300 |
$4K |
| D0230 |
Intraoral - periapical each additional radiographic image |
280 |
254 |
$3K |
| D1208 |
Topical application of fluoride, excluding varnish |
170 |
169 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
36 |
27 |
$3K |
| D1120 |
Prophylaxis - child |
57 |
57 |
$1K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
15 |
15 |
$551.33 |
| D1206 |
Topical application of fluoride varnish |
36 |
36 |
$549.00 |
| D0272 |
Bitewings - two radiographic images |
14 |
14 |
$228.67 |