| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,263 |
714 |
$108K |
| D1206 |
Topical application of fluoride varnish |
3,206 |
3,186 |
$93K |
| D0120 |
Periodic oral evaluation - established patient |
3,388 |
3,386 |
$92K |
| D1110 |
Prophylaxis - adult |
1,490 |
1,490 |
$62K |
| D1120 |
Prophylaxis - child |
1,825 |
1,825 |
$59K |
| D0274 |
Bitewings - four radiographic images |
1,944 |
1,944 |
$46K |
| D1999 |
|
4,189 |
3,875 |
$41K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
323 |
221 |
$26K |
| D0272 |
Bitewings - two radiographic images |
1,042 |
1,042 |
$17K |
| D0140 |
Limited oral evaluation - problem focused |
439 |
432 |
$12K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
130 |
130 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
156 |
145 |
$977.20 |
| D0210 |
Intraoral - complete series of radiographic images |
13 |
13 |
$561.84 |