| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
317 |
148 |
$31K |
| D1110 |
Prophylaxis - adult |
847 |
810 |
$31K |
| D0120 |
Periodic oral evaluation - established patient |
903 |
855 |
$21K |
| D0274 |
Bitewings - four radiographic images |
312 |
293 |
$9K |
| D0220 |
Intraoral - periapical first radiographic image |
555 |
499 |
$8K |
| D1208 |
Topical application of fluoride, excluding varnish |
465 |
402 |
$7K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
131 |
114 |
$5K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
72 |
41 |
$5K |
| D0230 |
Intraoral - periapical each additional radiographic image |
292 |
233 |
$3K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
30 |
13 |
$3K |
| D1120 |
Prophylaxis - child |
69 |
55 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
32 |
28 |
$981.61 |
| D0210 |
Intraoral - complete series of radiographic images |
13 |
13 |
$896.96 |
| D4355 |
|
13 |
13 |
$833.28 |