| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
923 |
192 |
$106K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
536 |
175 |
$49K |
| D1110 |
Prophylaxis - adult |
618 |
617 |
$34K |
| D0120 |
Periodic oral evaluation - established patient |
985 |
983 |
$27K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
285 |
102 |
$17K |
| D0210 |
Intraoral - complete series of radiographic images |
201 |
201 |
$13K |
| D0274 |
Bitewings - four radiographic images |
290 |
290 |
$8K |
| D0220 |
Intraoral - periapical first radiographic image |
529 |
529 |
$7K |
| D1120 |
Prophylaxis - child |
69 |
69 |
$3K |
| D1208 |
Topical application of fluoride, excluding varnish |
106 |
106 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
212 |
212 |
$2K |