| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
431 |
203 |
$31K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
716 |
714 |
$25K |
| D0210 |
Intraoral - complete series of radiographic images |
216 |
214 |
$13K |
| D0220 |
Intraoral - periapical first radiographic image |
811 |
785 |
$9K |
| D0274 |
Bitewings - four radiographic images |
232 |
232 |
$7K |
| D9110 |
|
114 |
112 |
$6K |
| D1208 |
Topical application of fluoride, excluding varnish |
300 |
300 |
$5K |
| D1110 |
Prophylaxis - adult |
93 |
93 |
$4K |
| D0230 |
Intraoral - periapical each additional radiographic image |
411 |
376 |
$4K |
| D1120 |
Prophylaxis - child |
52 |
52 |
$2K |
| D4346 |
|
12 |
12 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
53 |
49 |
$1K |