| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
308 |
115 |
$16K |
| D0274 |
Bitewings - four radiographic images |
580 |
578 |
$15K |
| D1110 |
Prophylaxis - adult |
339 |
336 |
$11K |
| D0220 |
Intraoral - periapical first radiographic image |
743 |
729 |
$6K |
| D0120 |
Periodic oral evaluation - established patient |
293 |
291 |
$6K |
| D0230 |
Intraoral - periapical each additional radiographic image |
688 |
677 |
$5K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
260 |
259 |
$5K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
80 |
36 |
$3K |
| D1206 |
Topical application of fluoride varnish |
51 |
51 |
$873.45 |
| D1330 |
|
120 |
118 |
$598.60 |
| D9110 |
|
20 |
20 |
$547.95 |
| D1310 |
|
106 |
104 |
$534.82 |
| D1120 |
Prophylaxis - child |
19 |
19 |
$404.22 |
| D0602 |
|
14 |
14 |
$140.00 |