| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
467 |
245 |
$55K |
| D1120 |
Prophylaxis - child |
891 |
891 |
$35K |
| D1206 |
Topical application of fluoride varnish |
1,291 |
1,291 |
$31K |
| D0120 |
Periodic oral evaluation - established patient |
916 |
916 |
$24K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,858 |
788 |
$19K |
| D0220 |
Intraoral - periapical first radiographic image |
1,123 |
1,055 |
$18K |
| D9310 |
|
250 |
250 |
$17K |
| D0210 |
Intraoral - complete series of radiographic images |
252 |
234 |
$11K |
| D2710 |
|
18 |
14 |
$11K |
| D1110 |
Prophylaxis - adult |
217 |
217 |
$10K |
| D0240 |
|
409 |
230 |
$9K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
144 |
144 |
$7K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
21 |
12 |
$3K |
| D0274 |
Bitewings - four radiographic images |
107 |
107 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
37 |
27 |
$3K |