| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
674 |
257 |
$114K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
577 |
223 |
$79K |
| D1110 |
Prophylaxis - adult |
413 |
410 |
$27K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
357 |
354 |
$20K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
117 |
44 |
$13K |
| D0120 |
Periodic oral evaluation - established patient |
320 |
320 |
$9K |
| D0210 |
Intraoral - complete series of radiographic images |
162 |
159 |
$9K |
| D1208 |
Topical application of fluoride, excluding varnish |
319 |
316 |
$7K |
| D1120 |
Prophylaxis - child |
145 |
142 |
$6K |
| D2335 |
|
34 |
12 |
$6K |
| D1206 |
Topical application of fluoride varnish |
213 |
213 |
$6K |
| D2332 |
|
30 |
14 |
$4K |
| D0274 |
Bitewings - four radiographic images |
178 |
178 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
168 |
157 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
38 |
37 |
$2K |
| D0272 |
Bitewings - two radiographic images |
14 |
14 |
$210.00 |