| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
706 |
367 |
$67K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
262 |
134 |
$19K |
| D0120 |
Periodic oral evaluation - established patient |
612 |
582 |
$14K |
| D1110 |
Prophylaxis - adult |
351 |
324 |
$11K |
| D1120 |
Prophylaxis - child |
383 |
373 |
$10K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
194 |
183 |
$8K |
| D0220 |
Intraoral - periapical first radiographic image |
476 |
410 |
$6K |
| D1208 |
Topical application of fluoride, excluding varnish |
264 |
251 |
$4K |
| D0230 |
Intraoral - periapical each additional radiographic image |
266 |
220 |
$3K |
| D1206 |
Topical application of fluoride varnish |
169 |
158 |
$3K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
26 |
15 |
$2K |
| D0330 |
Panoramic radiographic image |
22 |
20 |
$1K |
| D0272 |
Bitewings - two radiographic images |
49 |
48 |
$812.70 |
| D0274 |
Bitewings - four radiographic images |
21 |
20 |
$671.00 |