| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
620 |
368 |
$61K |
| D1110 |
Prophylaxis - adult |
1,585 |
1,544 |
$60K |
| D0120 |
Periodic oral evaluation - established patient |
1,735 |
1,685 |
$44K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
342 |
199 |
$24K |
| D0274 |
Bitewings - four radiographic images |
688 |
667 |
$21K |
| D1208 |
Topical application of fluoride, excluding varnish |
979 |
960 |
$16K |
| D0220 |
Intraoral - periapical first radiographic image |
945 |
895 |
$14K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
80 |
51 |
$10K |
| D0230 |
Intraoral - periapical each additional radiographic image |
599 |
433 |
$7K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
115 |
112 |
$5K |
| D1120 |
Prophylaxis - child |
88 |
85 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
38 |
37 |
$1K |
| D0330 |
Panoramic radiographic image |
13 |
13 |
$845.65 |