| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
433 |
283 |
$59K |
| D4342 |
|
592 |
168 |
$53K |
| D1110 |
Prophylaxis - adult |
894 |
878 |
$36K |
| D0210 |
Intraoral - complete series of radiographic images |
281 |
280 |
$23K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
197 |
119 |
$21K |
| D0120 |
Periodic oral evaluation - established patient |
868 |
855 |
$19K |
| D0180 |
|
312 |
309 |
$13K |
| D0274 |
Bitewings - four radiographic images |
260 |
258 |
$8K |
| D0220 |
Intraoral - periapical first radiographic image |
549 |
538 |
$7K |
| D4910 |
|
102 |
100 |
$7K |
| D0230 |
Intraoral - periapical each additional radiographic image |
474 |
463 |
$6K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
153 |
153 |
$6K |
| D0140 |
Limited oral evaluation - problem focused |
15 |
15 |
$504.45 |