| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
645 |
449 |
$75K |
| D1120 |
Prophylaxis - child |
1,452 |
1,452 |
$54K |
| D1110 |
Prophylaxis - adult |
844 |
844 |
$38K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,718 |
1,718 |
$37K |
| D0120 |
Periodic oral evaluation - established patient |
1,464 |
1,464 |
$37K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
679 |
679 |
$27K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
203 |
132 |
$18K |
| D0210 |
Intraoral - complete series of radiographic images |
203 |
203 |
$15K |
| D0220 |
Intraoral - periapical first radiographic image |
890 |
875 |
$14K |
| D0274 |
Bitewings - four radiographic images |
302 |
302 |
$9K |
| D0230 |
Intraoral - periapical each additional radiographic image |
817 |
403 |
$7K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
22 |
16 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
52 |
51 |
$2K |
| D0272 |
Bitewings - two radiographic images |
74 |
74 |
$2K |