| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
88 |
45 |
$12K |
| D0120 |
Periodic oral evaluation - established patient |
350 |
335 |
$8K |
| D1110 |
Prophylaxis - adult |
157 |
152 |
$6K |
| D0230 |
Intraoral - periapical each additional radiographic image |
347 |
330 |
$6K |
| D0220 |
Intraoral - periapical first radiographic image |
429 |
406 |
$5K |
| D0274 |
Bitewings - four radiographic images |
167 |
162 |
$5K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
106 |
101 |
$4K |
| D1206 |
Topical application of fluoride varnish |
105 |
99 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
12 |
12 |
$879.58 |
| D0140 |
Limited oral evaluation - problem focused |
13 |
13 |
$422.37 |