| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
943 |
513 |
$63K |
| D1110 |
Prophylaxis - adult |
1,186 |
1,183 |
$52K |
| D1206 |
Topical application of fluoride varnish |
891 |
887 |
$27K |
| D0120 |
Periodic oral evaluation - established patient |
940 |
936 |
$23K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
259 |
173 |
$14K |
| D0274 |
Bitewings - four radiographic images |
737 |
735 |
$8K |
| D1208 |
Topical application of fluoride, excluding varnish |
290 |
288 |
$7K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
269 |
269 |
$7K |
| D0210 |
Intraoral - complete series of radiographic images |
133 |
132 |
$6K |
| D0230 |
Intraoral - periapical each additional radiographic image |
944 |
937 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
1,059 |
1,053 |
$5K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
30 |
24 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
12 |
12 |
$495.00 |