| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
712 |
336 |
$60K |
| D1110 |
Prophylaxis - adult |
1,094 |
1,054 |
$35K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
473 |
233 |
$31K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
757 |
740 |
$18K |
| D0274 |
Bitewings - four radiographic images |
986 |
961 |
$16K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
168 |
96 |
$15K |
| D0120 |
Periodic oral evaluation - established patient |
826 |
784 |
$12K |
| D0220 |
Intraoral - periapical first radiographic image |
1,000 |
962 |
$6K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,085 |
726 |
$5K |
| D0140 |
Limited oral evaluation - problem focused |
250 |
236 |
$5K |