| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
395 |
167 |
$28K |
| D0120 |
Periodic oral evaluation - established patient |
803 |
803 |
$20K |
| D1110 |
Prophylaxis - adult |
440 |
440 |
$20K |
| D0140 |
Limited oral evaluation - problem focused |
439 |
368 |
$20K |
| D1120 |
Prophylaxis - child |
432 |
432 |
$19K |
| D1206 |
Topical application of fluoride varnish |
527 |
527 |
$16K |
| D0220 |
Intraoral - periapical first radiographic image |
1,081 |
1,039 |
$5K |
| D0230 |
Intraoral - periapical each additional radiographic image |
955 |
935 |
$4K |
| D0274 |
Bitewings - four radiographic images |
311 |
311 |
$4K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
123 |
123 |
$3K |
| D0210 |
Intraoral - complete series of radiographic images |
50 |
50 |
$2K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
23 |
12 |
$2K |
| D0272 |
Bitewings - two radiographic images |
165 |
165 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
20 |
12 |
$1K |