| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
587 |
334 |
$59K |
| D1120 |
Prophylaxis - child |
781 |
775 |
$37K |
| D0120 |
Periodic oral evaluation - established patient |
942 |
933 |
$30K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
182 |
121 |
$16K |
| D1110 |
Prophylaxis - adult |
208 |
206 |
$12K |
| D0140 |
Limited oral evaluation - problem focused |
209 |
204 |
$9K |
| D0272 |
Bitewings - two radiographic images |
324 |
322 |
$8K |
| D1206 |
Topical application of fluoride varnish |
338 |
335 |
$8K |
| D0274 |
Bitewings - four radiographic images |
204 |
203 |
$8K |
| D0220 |
Intraoral - periapical first radiographic image |
209 |
207 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
32 |
32 |
$2K |