| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
581 |
432 |
$22K |
| D0120 |
Periodic oral evaluation - established patient |
943 |
943 |
$19K |
| D1110 |
Prophylaxis - adult |
550 |
550 |
$11K |
| D1120 |
Prophylaxis - child |
325 |
325 |
$6K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
155 |
128 |
$6K |
| D0274 |
Bitewings - four radiographic images |
583 |
583 |
$5K |
| D0230 |
Intraoral - periapical each additional radiographic image |
642 |
639 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
925 |
923 |
$4K |
| D0140 |
Limited oral evaluation - problem focused |
170 |
169 |
$3K |
| D1208 |
Topical application of fluoride, excluding varnish |
224 |
224 |
$1K |
| D0272 |
Bitewings - two radiographic images |
142 |
142 |
$710.00 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
28 |
28 |
$560.00 |
| D0270 |
|
14 |
14 |
$42.00 |