| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
210 |
52 |
$14K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
189 |
42 |
$10K |
| D0120 |
Periodic oral evaluation - established patient |
548 |
418 |
$10K |
| D1110 |
Prophylaxis - adult |
208 |
164 |
$7K |
| D1208 |
Topical application of fluoride, excluding varnish |
687 |
524 |
$6K |
| D0220 |
Intraoral - periapical first radiographic image |
792 |
597 |
$6K |
| D0274 |
Bitewings - four radiographic images |
276 |
199 |
$5K |
| D0230 |
Intraoral - periapical each additional radiographic image |
736 |
514 |
$5K |
| D1120 |
Prophylaxis - child |
120 |
94 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
80 |
64 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
15 |
14 |
$918.32 |
| D0272 |
Bitewings - two radiographic images |
49 |
39 |
$678.02 |
| D0602 |
|
144 |
99 |
$0.00 |
| D0603 |
|
364 |
299 |
$0.00 |
| D0601 |
|
53 |
32 |
$0.00 |