| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
352 |
160 |
$28K |
| D1110 |
Prophylaxis - adult |
601 |
574 |
$20K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
485 |
433 |
$19K |
| D1206 |
Topical application of fluoride varnish |
681 |
663 |
$14K |
| D1120 |
Prophylaxis - child |
300 |
299 |
$13K |
| D1208 |
Topical application of fluoride, excluding varnish |
496 |
474 |
$10K |
| D0120 |
Periodic oral evaluation - established patient |
352 |
340 |
$9K |
| D0274 |
Bitewings - four radiographic images |
258 |
254 |
$9K |
| D0210 |
Intraoral - complete series of radiographic images |
142 |
129 |
$8K |
| D0140 |
Limited oral evaluation - problem focused |
67 |
65 |
$2K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
15 |
12 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
99 |
95 |
$1K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
16 |
13 |
$1K |