| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
57 |
29 |
$8K |
| D1110 |
Prophylaxis - adult |
86 |
85 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
54 |
53 |
$2K |
| D0120 |
Periodic oral evaluation - established patient |
75 |
72 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
19 |
19 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
30 |
28 |
$936.61 |
| D0274 |
Bitewings - four radiographic images |
28 |
27 |
$787.92 |
| D1206 |
Topical application of fluoride varnish |
29 |
29 |
$470.96 |
| D0220 |
Intraoral - periapical first radiographic image |
27 |
25 |
$321.33 |