| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
275 |
139 |
$20K |
| D1110 |
Prophylaxis - adult |
477 |
459 |
$17K |
| D0274 |
Bitewings - four radiographic images |
463 |
450 |
$14K |
| D0230 |
Intraoral - periapical each additional radiographic image |
914 |
479 |
$10K |
| D0120 |
Periodic oral evaluation - established patient |
375 |
369 |
$8K |
| D0220 |
Intraoral - periapical first radiographic image |
694 |
663 |
$8K |
| D0140 |
Limited oral evaluation - problem focused |
258 |
241 |
$8K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
122 |
67 |
$7K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
53 |
28 |
$4K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
26 |
26 |
$1K |