| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
206 |
127 |
$22K |
| D1110 |
Prophylaxis - adult |
467 |
466 |
$20K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
267 |
267 |
$10K |
| D0120 |
Periodic oral evaluation - established patient |
373 |
373 |
$9K |
| D0210 |
Intraoral - complete series of radiographic images |
132 |
131 |
$7K |
| D1120 |
Prophylaxis - child |
140 |
140 |
$6K |
| D1208 |
Topical application of fluoride, excluding varnish |
242 |
241 |
$5K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
27 |
17 |
$4K |
| D0274 |
Bitewings - four radiographic images |
125 |
125 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
12 |
12 |
$527.60 |
| D0220 |
Intraoral - periapical first radiographic image |
37 |
36 |
$508.60 |