| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
304 |
161 |
$58K |
| D0210 |
Intraoral - complete series of radiographic images |
479 |
415 |
$41K |
| D1110 |
Prophylaxis - adult |
628 |
562 |
$40K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
502 |
447 |
$32K |
| D0120 |
Periodic oral evaluation - established patient |
290 |
237 |
$10K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
55 |
29 |
$7K |
| D0274 |
Bitewings - four radiographic images |
106 |
106 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
57 |
57 |
$1K |