| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,369 |
797 |
$75K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
838 |
508 |
$35K |
| D1110 |
Prophylaxis - adult |
524 |
521 |
$18K |
| D0274 |
Bitewings - four radiographic images |
589 |
585 |
$12K |
| D0210 |
Intraoral - complete series of radiographic images |
603 |
277 |
$9K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
121 |
91 |
$9K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
330 |
325 |
$8K |
| D0120 |
Periodic oral evaluation - established patient |
501 |
498 |
$7K |
| D0140 |
Limited oral evaluation - problem focused |
182 |
171 |
$4K |
| D1120 |
Prophylaxis - child |
109 |
109 |
$3K |
| D1208 |
Topical application of fluoride, excluding varnish |
219 |
219 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
373 |
362 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
108 |
76 |
$232.48 |