| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
148 |
105 |
$25K |
| D1206 |
Topical application of fluoride varnish |
537 |
537 |
$22K |
| D1120 |
Prophylaxis - child |
322 |
322 |
$17K |
| D0120 |
Periodic oral evaluation - established patient |
393 |
393 |
$17K |
| D0220 |
Intraoral - periapical first radiographic image |
629 |
620 |
$15K |
| D0230 |
Intraoral - periapical each additional radiographic image |
593 |
519 |
$14K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
82 |
60 |
$12K |
| D0274 |
Bitewings - four radiographic images |
176 |
176 |
$9K |
| D0272 |
Bitewings - two radiographic images |
232 |
232 |
$9K |
| D1110 |
Prophylaxis - adult |
130 |
130 |
$8K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
104 |
104 |
$7K |
| D0210 |
Intraoral - complete series of radiographic images |
60 |
27 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
15 |
13 |
$1K |