| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
149 |
106 |
$8K |
| D1110 |
Prophylaxis - adult |
270 |
254 |
$7K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
370 |
346 |
$7K |
| D1206 |
Topical application of fluoride varnish |
278 |
265 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
162 |
152 |
$3K |
| D0274 |
Bitewings - four radiographic images |
150 |
139 |
$2K |
| D1120 |
Prophylaxis - child |
117 |
109 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
58 |
39 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
48 |
42 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
146 |
134 |
$1K |
| D0120 |
Periodic oral evaluation - established patient |
34 |
33 |
$621.75 |
| D0272 |
Bitewings - two radiographic images |
12 |
12 |
$158.90 |