| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
85 |
50 |
$6K |
| D0274 |
Bitewings - four radiographic images |
95 |
94 |
$3K |
| D0120 |
Periodic oral evaluation - established patient |
117 |
112 |
$2K |
| D1110 |
Prophylaxis - adult |
36 |
35 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
206 |
195 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
55 |
52 |
$1K |
| D1206 |
Topical application of fluoride varnish |
102 |
99 |
$1K |
| D1120 |
Prophylaxis - child |
26 |
26 |
$1K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
27 |
27 |
$816.40 |
| D0230 |
Intraoral - periapical each additional radiographic image |
125 |
109 |
$666.60 |