| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
369 |
195 |
$25K |
| D1110 |
Prophylaxis - adult |
329 |
326 |
$14K |
| D0210 |
Intraoral - complete series of radiographic images |
152 |
152 |
$7K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
247 |
232 |
$6K |
| D0120 |
Periodic oral evaluation - established patient |
189 |
189 |
$5K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
13 |
12 |
$710.00 |
| D1120 |
Prophylaxis - child |
13 |
13 |
$385.00 |
| D0220 |
Intraoral - periapical first radiographic image |
75 |
74 |
$365.00 |
| D0274 |
Bitewings - four radiographic images |
28 |
28 |
$312.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
14 |
14 |
$81.00 |