| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
415 |
214 |
$46K |
| D1110 |
Prophylaxis - adult |
779 |
772 |
$32K |
| D1120 |
Prophylaxis - child |
479 |
479 |
$19K |
| D0120 |
Periodic oral evaluation - established patient |
742 |
738 |
$18K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
162 |
80 |
$15K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,714 |
666 |
$15K |
| D0220 |
Intraoral - periapical first radiographic image |
932 |
882 |
$13K |
| D1208 |
Topical application of fluoride, excluding varnish |
546 |
546 |
$13K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
303 |
300 |
$12K |
| D0140 |
Limited oral evaluation - problem focused |
308 |
303 |
$11K |
| D0274 |
Bitewings - four radiographic images |
216 |
216 |
$6K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
15 |
12 |
$2K |
| D0272 |
Bitewings - two radiographic images |
12 |
12 |
$273.38 |