| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
469 |
194 |
$23K |
| D0210 |
Intraoral - complete series of radiographic images |
390 |
361 |
$20K |
| D1110 |
Prophylaxis - adult |
564 |
532 |
$17K |
| D0120 |
Periodic oral evaluation - established patient |
1,056 |
1,007 |
$17K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
196 |
111 |
$10K |
| D1208 |
Topical application of fluoride, excluding varnish |
691 |
654 |
$9K |
| D1120 |
Prophylaxis - child |
485 |
454 |
$9K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
360 |
334 |
$9K |
| D0274 |
Bitewings - four radiographic images |
472 |
446 |
$9K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
61 |
30 |
$4K |
| D0140 |
Limited oral evaluation - problem focused |
46 |
45 |
$1K |
| D0272 |
Bitewings - two radiographic images |
99 |
93 |
$920.00 |
| D0220 |
Intraoral - periapical first radiographic image |
162 |
141 |
$705.00 |