| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
449 |
184 |
$35K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
299 |
158 |
$29K |
| D1110 |
Prophylaxis - adult |
498 |
498 |
$25K |
| D0120 |
Periodic oral evaluation - established patient |
800 |
800 |
$18K |
| D1120 |
Prophylaxis - child |
386 |
386 |
$13K |
| D1208 |
Topical application of fluoride, excluding varnish |
776 |
776 |
$13K |
| D0272 |
Bitewings - two radiographic images |
658 |
658 |
$12K |
| D0220 |
Intraoral - periapical first radiographic image |
905 |
888 |
$11K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,260 |
707 |
$10K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
65 |
36 |
$8K |
| D0330 |
Panoramic radiographic image |
154 |
154 |
$8K |
| D0140 |
Limited oral evaluation - problem focused |
126 |
125 |
$5K |
| D0274 |
Bitewings - four radiographic images |
160 |
160 |
$4K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
100 |
100 |
$4K |