| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
250 |
159 |
$30K |
| D0120 |
Periodic oral evaluation - established patient |
786 |
786 |
$21K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
236 |
151 |
$20K |
| D1120 |
Prophylaxis - child |
488 |
488 |
$20K |
| D1110 |
Prophylaxis - adult |
305 |
305 |
$15K |
| D1206 |
Topical application of fluoride varnish |
543 |
543 |
$11K |
| D0220 |
Intraoral - periapical first radiographic image |
515 |
511 |
$8K |
| D0274 |
Bitewings - four radiographic images |
213 |
213 |
$7K |
| D0230 |
Intraoral - periapical each additional radiographic image |
664 |
418 |
$6K |
| D1352 |
|
53 |
15 |
$4K |
| D0210 |
Intraoral - complete series of radiographic images |
27 |
27 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
29 |
29 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
28 |
28 |
$1K |