| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
224 |
133 |
$16K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
195 |
119 |
$11K |
| D1110 |
Prophylaxis - adult |
194 |
194 |
$9K |
| D0120 |
Periodic oral evaluation - established patient |
224 |
224 |
$6K |
| D1206 |
Topical application of fluoride varnish |
127 |
127 |
$4K |
| D0274 |
Bitewings - four radiographic images |
193 |
193 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
42 |
42 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
247 |
247 |
$1K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
45 |
45 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
222 |
222 |
$1K |
| D0603 |
|
112 |
112 |
$1K |
| D1120 |
Prophylaxis - child |
12 |
12 |
$540.00 |