| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
398 |
200 |
$52K |
| D1110 |
Prophylaxis - adult |
631 |
629 |
$41K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
167 |
88 |
$26K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
346 |
335 |
$19K |
| D1208 |
Topical application of fluoride, excluding varnish |
650 |
640 |
$15K |
| D0120 |
Periodic oral evaluation - established patient |
476 |
475 |
$15K |
| D0330 |
Panoramic radiographic image |
335 |
322 |
$15K |
| D0274 |
Bitewings - four radiographic images |
547 |
534 |
$13K |
| D0220 |
Intraoral - periapical first radiographic image |
784 |
763 |
$8K |
| D0230 |
Intraoral - periapical each additional radiographic image |
604 |
589 |
$5K |
| D0140 |
Limited oral evaluation - problem focused |
86 |
84 |
$4K |
| D4341 |
|
38 |
14 |
$3K |
| D1120 |
Prophylaxis - child |
13 |
13 |
$633.15 |
| D1330 |
|
12 |
12 |
$72.00 |