| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
531 |
294 |
$27K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
558 |
300 |
$26K |
| D1110 |
Prophylaxis - adult |
768 |
744 |
$24K |
| D0120 |
Periodic oral evaluation - established patient |
1,261 |
1,199 |
$21K |
| D1120 |
Prophylaxis - child |
801 |
774 |
$15K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,020 |
976 |
$15K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
517 |
498 |
$13K |
| D0274 |
Bitewings - four radiographic images |
459 |
440 |
$8K |
| D0140 |
Limited oral evaluation - problem focused |
265 |
253 |
$5K |
| D0210 |
Intraoral - complete series of radiographic images |
103 |
99 |
$5K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
77 |
48 |
$4K |
| D0330 |
Panoramic radiographic image |
75 |
73 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
440 |
418 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
130 |
67 |
$593.75 |
| D0350 |
|
23 |
23 |
$289.33 |