| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
104 |
57 |
$5K |
| D1110 |
Prophylaxis - adult |
140 |
131 |
$4K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
135 |
117 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
53 |
24 |
$3K |
| D0274 |
Bitewings - four radiographic images |
129 |
120 |
$2K |
| D0120 |
Periodic oral evaluation - established patient |
138 |
130 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
79 |
73 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
73 |
72 |
$1K |
| D1120 |
Prophylaxis - child |
43 |
42 |
$762.00 |
| D0220 |
Intraoral - periapical first radiographic image |
15 |
13 |
$66.00 |