| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
758 |
393 |
$86K |
| D1110 |
Prophylaxis - adult |
1,059 |
1,051 |
$53K |
| D0120 |
Periodic oral evaluation - established patient |
1,776 |
1,766 |
$48K |
| D1120 |
Prophylaxis - child |
1,050 |
1,049 |
$42K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
489 |
279 |
$38K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,324 |
1,323 |
$32K |
| D0220 |
Intraoral - periapical first radiographic image |
623 |
615 |
$10K |
| D0274 |
Bitewings - four radiographic images |
283 |
282 |
$10K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
178 |
178 |
$7K |
| D0210 |
Intraoral - complete series of radiographic images |
84 |
83 |
$5K |
| D0140 |
Limited oral evaluation - problem focused |
112 |
104 |
$4K |
| D0230 |
Intraoral - periapical each additional radiographic image |
334 |
284 |
$3K |
| D0272 |
Bitewings - two radiographic images |
44 |
44 |
$1K |