| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
186 |
118 |
$13K |
| D1110 |
Prophylaxis - adult |
263 |
263 |
$12K |
| D0120 |
Periodic oral evaluation - established patient |
297 |
297 |
$9K |
| D0274 |
Bitewings - four radiographic images |
186 |
186 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
410 |
406 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
25 |
17 |
$1K |
| D1120 |
Prophylaxis - child |
25 |
25 |
$1K |
| D1208 |
Topical application of fluoride, excluding varnish |
43 |
43 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
324 |
323 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
76 |
74 |
$897.00 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
13 |
13 |
$585.00 |
| D0272 |
Bitewings - two radiographic images |
47 |
47 |
$470.00 |