| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
714 |
326 |
$30K |
| D1110 |
Prophylaxis - adult |
743 |
688 |
$28K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
469 |
242 |
$25K |
| D0330 |
Panoramic radiographic image |
503 |
471 |
$17K |
| D0120 |
Periodic oral evaluation - established patient |
869 |
785 |
$15K |
| D0274 |
Bitewings - four radiographic images |
591 |
550 |
$13K |
| D1208 |
Topical application of fluoride, excluding varnish |
682 |
628 |
$9K |
| D1120 |
Prophylaxis - child |
160 |
146 |
$6K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
261 |
248 |
$6K |
| D0220 |
Intraoral - periapical first radiographic image |
853 |
768 |
$6K |
| D0230 |
Intraoral - periapical each additional radiographic image |
358 |
98 |
$2K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
20 |
13 |
$1K |
| D0272 |
Bitewings - two radiographic images |
38 |
37 |
$594.29 |
| D0140 |
Limited oral evaluation - problem focused |
14 |
12 |
$282.15 |