| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
903 |
489 |
$75K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
627 |
355 |
$42K |
| D1110 |
Prophylaxis - adult |
1,130 |
1,120 |
$42K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,903 |
1,890 |
$34K |
| D0120 |
Periodic oral evaluation - established patient |
2,018 |
2,003 |
$34K |
| D1120 |
Prophylaxis - child |
704 |
701 |
$21K |
| D0274 |
Bitewings - four radiographic images |
943 |
938 |
$20K |
| D4355 |
|
200 |
200 |
$16K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
96 |
73 |
$14K |
| D0140 |
Limited oral evaluation - problem focused |
385 |
375 |
$10K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
333 |
330 |
$10K |
| D0210 |
Intraoral - complete series of radiographic images |
208 |
201 |
$7K |
| D0220 |
Intraoral - periapical first radiographic image |
674 |
633 |
$6K |
| D0330 |
Panoramic radiographic image |
76 |
76 |
$5K |
| D0272 |
Bitewings - two radiographic images |
56 |
56 |
$1K |