| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
664 |
361 |
$92K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
261 |
147 |
$44K |
| D1110 |
Prophylaxis - adult |
685 |
676 |
$28K |
| D0120 |
Periodic oral evaluation - established patient |
1,013 |
1,004 |
$23K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
516 |
508 |
$20K |
| D0274 |
Bitewings - four radiographic images |
527 |
520 |
$15K |
| D0220 |
Intraoral - periapical first radiographic image |
1,083 |
1,060 |
$13K |
| D0230 |
Intraoral - periapical each additional radiographic image |
652 |
642 |
$13K |
| D0210 |
Intraoral - complete series of radiographic images |
243 |
240 |
$9K |
| D0140 |
Limited oral evaluation - problem focused |
246 |
233 |
$8K |
| D3910 |
|
79 |
12 |
$7K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
60 |
33 |
$6K |
| D4910 |
|
59 |
57 |
$4K |
| D1206 |
Topical application of fluoride varnish |
13 |
13 |
$211.12 |