| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
372 |
139 |
$45K |
| D1120 |
Prophylaxis - child |
291 |
291 |
$12K |
| D0120 |
Periodic oral evaluation - established patient |
358 |
358 |
$10K |
| D1208 |
Topical application of fluoride, excluding varnish |
356 |
356 |
$9K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
53 |
29 |
$8K |
| D1110 |
Prophylaxis - adult |
86 |
86 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
167 |
166 |
$3K |
| D0210 |
Intraoral - complete series of radiographic images |
28 |
28 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
212 |
133 |
$2K |
| D0274 |
Bitewings - four radiographic images |
49 |
49 |
$2K |
| D0272 |
Bitewings - two radiographic images |
29 |
29 |
$725.00 |
| D0140 |
Limited oral evaluation - problem focused |
12 |
12 |
$540.00 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
12 |
12 |
$506.30 |