| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
220 |
143 |
$14K |
| D0140 |
Limited oral evaluation - problem focused |
590 |
560 |
$14K |
| D1110 |
Prophylaxis - adult |
157 |
152 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
171 |
163 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
28 |
27 |
$2K |
| D0120 |
Periodic oral evaluation - established patient |
82 |
76 |
$1K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
38 |
38 |
$1K |
| D1206 |
Topical application of fluoride varnish |
62 |
58 |
$904.55 |
| D0272 |
Bitewings - two radiographic images |
48 |
45 |
$760.14 |