| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
636 |
472 |
$24K |
| D0120 |
Periodic oral evaluation - established patient |
974 |
974 |
$19K |
| D1110 |
Prophylaxis - adult |
535 |
535 |
$11K |
| D1120 |
Prophylaxis - child |
476 |
476 |
$9K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
232 |
195 |
$8K |
| D0274 |
Bitewings - four radiographic images |
609 |
609 |
$5K |
| D0140 |
Limited oral evaluation - problem focused |
204 |
201 |
$4K |
| D0230 |
Intraoral - periapical each additional radiographic image |
653 |
653 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
905 |
898 |
$4K |
| D1208 |
Topical application of fluoride, excluding varnish |
412 |
412 |
$2K |
| D0272 |
Bitewings - two radiographic images |
249 |
249 |
$1K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
15 |
13 |
$620.00 |
| D0270 |
|
122 |
119 |
$351.00 |