| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,561 |
651 |
$102K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,079 |
442 |
$58K |
| D0120 |
Periodic oral evaluation - established patient |
317 |
317 |
$17K |
| D1110 |
Prophylaxis - adult |
191 |
191 |
$17K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,291 |
693 |
$10K |
| D1120 |
Prophylaxis - child |
280 |
279 |
$9K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
121 |
121 |
$7K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
54 |
38 |
$4K |
| D0274 |
Bitewings - four radiographic images |
196 |
196 |
$4K |
| D0210 |
Intraoral - complete series of radiographic images |
38 |
38 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
39 |
39 |
$415.50 |
| D0272 |
Bitewings - two radiographic images |
14 |
14 |
$168.00 |
| D0220 |
Intraoral - periapical first radiographic image |
13 |
13 |
$156.00 |