| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
368 |
191 |
$46K |
| D1120 |
Prophylaxis - child |
817 |
817 |
$33K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
290 |
183 |
$27K |
| D0120 |
Periodic oral evaluation - established patient |
892 |
891 |
$25K |
| D1206 |
Topical application of fluoride varnish |
906 |
906 |
$22K |
| D1110 |
Prophylaxis - adult |
290 |
290 |
$15K |
| D0274 |
Bitewings - four radiographic images |
314 |
313 |
$11K |
| D0140 |
Limited oral evaluation - problem focused |
225 |
218 |
$10K |
| D0220 |
Intraoral - periapical first radiographic image |
378 |
362 |
$6K |
| D0230 |
Intraoral - periapical each additional radiographic image |
466 |
260 |
$4K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
62 |
62 |
$3K |
| D0240 |
|
23 |
12 |
$506.00 |
| D0272 |
Bitewings - two radiographic images |
14 |
14 |
$350.00 |