| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
584 |
283 |
$55K |
| D2394 |
|
149 |
89 |
$18K |
| D1110 |
Prophylaxis - adult |
535 |
524 |
$17K |
| D0274 |
Bitewings - four radiographic images |
525 |
513 |
$15K |
| D2161 |
|
126 |
62 |
$13K |
| D0120 |
Periodic oral evaluation - established patient |
584 |
576 |
$12K |
| D0210 |
Intraoral - complete series of radiographic images |
201 |
195 |
$11K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
232 |
217 |
$8K |
| D0140 |
Limited oral evaluation - problem focused |
219 |
209 |
$6K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
47 |
27 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
126 |
113 |
$1K |
| D1208 |
Topical application of fluoride, excluding varnish |
12 |
12 |
$312.62 |