| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
308 |
128 |
$24K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,556 |
400 |
$18K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
268 |
91 |
$15K |
| D0120 |
Periodic oral evaluation - established patient |
507 |
494 |
$12K |
| D1110 |
Prophylaxis - adult |
320 |
313 |
$10K |
| D0274 |
Bitewings - four radiographic images |
217 |
216 |
$7K |
| D1120 |
Prophylaxis - child |
84 |
81 |
$4K |
| D0140 |
Limited oral evaluation - problem focused |
115 |
110 |
$3K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
15 |
12 |
$1K |
| D1206 |
Topical application of fluoride varnish |
40 |
38 |
$1K |
| D0272 |
Bitewings - two radiographic images |
14 |
13 |
$407.68 |
| D1208 |
Topical application of fluoride, excluding varnish |
13 |
13 |
$369.46 |