| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
814 |
403 |
$119K |
| D0120 |
Periodic oral evaluation - established patient |
1,120 |
824 |
$37K |
| D1110 |
Prophylaxis - adult |
629 |
448 |
$37K |
| D0220 |
Intraoral - periapical first radiographic image |
1,917 |
1,405 |
$34K |
| D1120 |
Prophylaxis - child |
409 |
294 |
$19K |
| D0274 |
Bitewings - four radiographic images |
428 |
303 |
$17K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
331 |
244 |
$15K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,047 |
673 |
$15K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
67 |
39 |
$13K |
| D0140 |
Limited oral evaluation - problem focused |
259 |
164 |
$11K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
27 |
15 |
$3K |
| D0272 |
Bitewings - two radiographic images |
111 |
77 |
$3K |
| D1208 |
Topical application of fluoride, excluding varnish |
33 |
24 |
$733.00 |