| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,845 |
853 |
$73K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,649 |
729 |
$53K |
| D1110 |
Prophylaxis - adult |
2,654 |
2,589 |
$45K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,529 |
1,515 |
$32K |
| D0120 |
Periodic oral evaluation - established patient |
1,614 |
1,567 |
$24K |
| D0274 |
Bitewings - four radiographic images |
2,007 |
1,957 |
$18K |
| D0230 |
Intraoral - periapical each additional radiographic image |
3,720 |
2,616 |
$13K |
| D0220 |
Intraoral - periapical first radiographic image |
2,986 |
2,800 |
$11K |
| D0140 |
Limited oral evaluation - problem focused |
801 |
757 |
$11K |
| D0210 |
Intraoral - complete series of radiographic images |
40 |
40 |
$1K |
| D1208 |
Topical application of fluoride, excluding varnish |
26 |
26 |
$235.00 |
| D1120 |
Prophylaxis - child |
13 |
13 |
$193.00 |