| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
206 |
119 |
$18K |
| D1208 |
Topical application of fluoride, excluding varnish |
662 |
662 |
$14K |
| D1120 |
Prophylaxis - child |
405 |
405 |
$14K |
| D0120 |
Periodic oral evaluation - established patient |
523 |
523 |
$11K |
| D1110 |
Prophylaxis - adult |
212 |
212 |
$10K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
120 |
74 |
$9K |
| D0274 |
Bitewings - four radiographic images |
261 |
261 |
$7K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
97 |
97 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
41 |
41 |
$1K |
| D9920 |
|
13 |
12 |
$890.50 |
| D0210 |
Intraoral - complete series of radiographic images |
14 |
14 |
$609.16 |
| D0220 |
Intraoral - periapical first radiographic image |
39 |
39 |
$436.02 |