| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
185 |
100 |
$21K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
259 |
258 |
$10K |
| D1120 |
Prophylaxis - child |
221 |
221 |
$9K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
76 |
43 |
$6K |
| D0140 |
Limited oral evaluation - problem focused |
137 |
134 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
306 |
300 |
$5K |
| D1206 |
Topical application of fluoride varnish |
192 |
192 |
$4K |
| D1110 |
Prophylaxis - adult |
52 |
51 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
252 |
241 |
$2K |
| D0274 |
Bitewings - four radiographic images |
57 |
57 |
$2K |
| D0272 |
Bitewings - two radiographic images |
64 |
64 |
$1K |
| D0120 |
Periodic oral evaluation - established patient |
30 |
30 |
$756.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
13 |
13 |
$300.00 |