| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
504 |
287 |
$62K |
| D1110 |
Prophylaxis - adult |
973 |
960 |
$44K |
| D0120 |
Periodic oral evaluation - established patient |
1,457 |
1,446 |
$37K |
| D1120 |
Prophylaxis - child |
727 |
727 |
$29K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
249 |
167 |
$23K |
| D0274 |
Bitewings - four radiographic images |
624 |
619 |
$20K |
| D1208 |
Topical application of fluoride, excluding varnish |
798 |
798 |
$20K |
| D0220 |
Intraoral - periapical first radiographic image |
878 |
870 |
$14K |
| D0230 |
Intraoral - periapical each additional radiographic image |
826 |
769 |
$7K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
22 |
14 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
16 |
14 |
$494.00 |
| D0140 |
Limited oral evaluation - problem focused |
12 |
12 |
$486.00 |