| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
247 |
143 |
$30K |
| D1120 |
Prophylaxis - child |
373 |
373 |
$15K |
| D1110 |
Prophylaxis - adult |
269 |
269 |
$12K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
284 |
284 |
$11K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
70 |
52 |
$10K |
| D0120 |
Periodic oral evaluation - established patient |
363 |
363 |
$9K |
| D1208 |
Topical application of fluoride, excluding varnish |
367 |
365 |
$8K |
| D0220 |
Intraoral - periapical first radiographic image |
481 |
458 |
$7K |
| D0230 |
Intraoral - periapical each additional radiographic image |
400 |
312 |
$3K |
| D1206 |
Topical application of fluoride varnish |
67 |
67 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
24 |
24 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
29 |
29 |
$1K |
| D0274 |
Bitewings - four radiographic images |
28 |
28 |
$890.00 |