| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
208 |
77 |
$15K |
| D0140 |
Limited oral evaluation - problem focused |
191 |
150 |
$6K |
| D1110 |
Prophylaxis - adult |
152 |
136 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
317 |
239 |
$3K |
| D0274 |
Bitewings - four radiographic images |
120 |
112 |
$3K |
| D1206 |
Topical application of fluoride varnish |
167 |
155 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
277 |
155 |
$3K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
29 |
15 |
$3K |
| D0120 |
Periodic oral evaluation - established patient |
56 |
48 |
$990.50 |