| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
100 |
58 |
$11K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
114 |
58 |
$10K |
| D1120 |
Prophylaxis - child |
226 |
226 |
$9K |
| D0210 |
Intraoral - complete series of radiographic images |
115 |
113 |
$7K |
| D1208 |
Topical application of fluoride, excluding varnish |
247 |
247 |
$6K |
| D0120 |
Periodic oral evaluation - established patient |
201 |
201 |
$5K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
124 |
122 |
$4K |
| D1110 |
Prophylaxis - adult |
72 |
72 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
196 |
193 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
168 |
128 |
$1K |
| D0272 |
Bitewings - two radiographic images |
45 |
45 |
$1K |
| D0274 |
Bitewings - four radiographic images |
18 |
18 |
$639.00 |
| D0140 |
Limited oral evaluation - problem focused |
14 |
14 |
$471.46 |