| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
947 |
534 |
$71K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
616 |
389 |
$62K |
| D1110 |
Prophylaxis - adult |
1,383 |
1,345 |
$48K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
843 |
812 |
$34K |
| D0120 |
Periodic oral evaluation - established patient |
1,511 |
1,483 |
$32K |
| D0330 |
Panoramic radiographic image |
513 |
490 |
$28K |
| D0140 |
Limited oral evaluation - problem focused |
764 |
735 |
$26K |
| D0210 |
Intraoral - complete series of radiographic images |
357 |
345 |
$25K |
| D0220 |
Intraoral - periapical first radiographic image |
598 |
567 |
$9K |
| D1206 |
Topical application of fluoride varnish |
416 |
408 |
$7K |
| D0230 |
Intraoral - periapical each additional radiographic image |
361 |
113 |
$4K |
| D0274 |
Bitewings - four radiographic images |
76 |
73 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
101 |
101 |
$2K |
| D1120 |
Prophylaxis - child |
26 |
26 |
$711.50 |