| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
473 |
235 |
$25K |
| D1110 |
Prophylaxis - adult |
752 |
751 |
$25K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
368 |
187 |
$16K |
| D0274 |
Bitewings - four radiographic images |
596 |
595 |
$16K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
180 |
93 |
$11K |
| D0120 |
Periodic oral evaluation - established patient |
462 |
461 |
$9K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
318 |
318 |
$6K |
| D0220 |
Intraoral - periapical first radiographic image |
693 |
675 |
$5K |
| D0230 |
Intraoral - periapical each additional radiographic image |
521 |
487 |
$4K |
| D2330 |
|
58 |
24 |
$3K |
| D9110 |
|
73 |
73 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
76 |
76 |
$1K |
| D1330 |
|
62 |
62 |
$300.00 |
| D0272 |
Bitewings - two radiographic images |
12 |
12 |
$191.12 |