| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,047 |
170 |
$66K |
| D1110 |
Prophylaxis - adult |
942 |
924 |
$36K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,603 |
1,590 |
$30K |
| D0120 |
Periodic oral evaluation - established patient |
1,617 |
1,604 |
$27K |
| D1120 |
Prophylaxis - child |
737 |
735 |
$23K |
| D0274 |
Bitewings - four radiographic images |
389 |
379 |
$9K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
89 |
38 |
$8K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
205 |
177 |
$6K |
| D0140 |
Limited oral evaluation - problem focused |
13 |
13 |
$322.79 |
| D0272 |
Bitewings - two radiographic images |
12 |
12 |
$241.80 |
| D0220 |
Intraoral - periapical first radiographic image |
30 |
26 |
$174.36 |