| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
346 |
197 |
$27K |
| D0120 |
Periodic oral evaluation - established patient |
886 |
886 |
$23K |
| D1120 |
Prophylaxis - child |
710 |
710 |
$17K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
216 |
142 |
$13K |
| D1206 |
Topical application of fluoride varnish |
811 |
811 |
$13K |
| D1110 |
Prophylaxis - adult |
274 |
274 |
$9K |
| D0274 |
Bitewings - four radiographic images |
352 |
352 |
$9K |
| D0272 |
Bitewings - two radiographic images |
540 |
540 |
$8K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
131 |
131 |
$6K |
| D0330 |
Panoramic radiographic image |
57 |
57 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
91 |
91 |
$926.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
79 |
71 |
$880.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
12 |
12 |
$144.00 |