| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
341 |
182 |
$31K |
| D1110 |
Prophylaxis - adult |
599 |
596 |
$23K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
450 |
394 |
$12K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
139 |
83 |
$11K |
| D0274 |
Bitewings - four radiographic images |
401 |
392 |
$10K |
| D0120 |
Periodic oral evaluation - established patient |
579 |
578 |
$9K |
| D0220 |
Intraoral - periapical first radiographic image |
607 |
563 |
$5K |
| D0230 |
Intraoral - periapical each additional radiographic image |
323 |
272 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
85 |
80 |
$2K |
| D1120 |
Prophylaxis - child |
69 |
69 |
$2K |
| D9994 |
|
251 |
227 |
$2K |
| D9920 |
|
40 |
39 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
76 |
76 |
$2K |
| D1206 |
Topical application of fluoride varnish |
96 |
96 |
$1K |