| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
104 |
54 |
$9K |
| D0230 |
Intraoral - periapical each additional radiographic image |
997 |
480 |
$9K |
| D1120 |
Prophylaxis - child |
245 |
245 |
$7K |
| D1208 |
Topical application of fluoride, excluding varnish |
360 |
360 |
$7K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
474 |
471 |
$7K |
| D1110 |
Prophylaxis - adult |
139 |
138 |
$6K |
| D0220 |
Intraoral - periapical first radiographic image |
561 |
555 |
$5K |
| D0120 |
Periodic oral evaluation - established patient |
242 |
242 |
$4K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
58 |
27 |
$4K |
| D0274 |
Bitewings - four radiographic images |
108 |
108 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
54 |
54 |
$695.24 |
| D0272 |
Bitewings - two radiographic images |
42 |
42 |
$644.80 |