| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
359 |
166 |
$3K |
| D0120 |
Periodic oral evaluation - established patient |
1,278 |
1,141 |
$2K |
| D1110 |
Prophylaxis - adult |
544 |
480 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,089 |
969 |
$2K |
| D1120 |
Prophylaxis - child |
885 |
794 |
$1K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
377 |
168 |
$960.15 |
| D0210 |
Intraoral - complete series of radiographic images |
60 |
52 |
$550.83 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
133 |
117 |
$518.30 |
| D0274 |
Bitewings - four radiographic images |
340 |
299 |
$291.91 |
| D0272 |
Bitewings - two radiographic images |
246 |
222 |
$222.05 |
| D0140 |
Limited oral evaluation - problem focused |
135 |
117 |
$148.32 |
| D0220 |
Intraoral - periapical first radiographic image |
47 |
40 |
$0.00 |