| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
362 |
220 |
$40K |
| D0120 |
Periodic oral evaluation - established patient |
1,125 |
1,122 |
$28K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
319 |
161 |
$25K |
| D1110 |
Prophylaxis - adult |
507 |
506 |
$22K |
| D1206 |
Topical application of fluoride varnish |
850 |
850 |
$20K |
| D1120 |
Prophylaxis - child |
429 |
429 |
$16K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
272 |
266 |
$10K |
| D0210 |
Intraoral - complete series of radiographic images |
74 |
71 |
$4K |
| D0274 |
Bitewings - four radiographic images |
38 |
38 |
$1K |
| D0272 |
Bitewings - two radiographic images |
12 |
12 |
$249.00 |
| D0220 |
Intraoral - periapical first radiographic image |
12 |
12 |
$183.60 |