| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
599 |
254 |
$48K |
| D9945 |
|
103 |
103 |
$40K |
| D1110 |
Prophylaxis - adult |
628 |
564 |
$26K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
277 |
127 |
$23K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
658 |
580 |
$20K |
| D0210 |
Intraoral - complete series of radiographic images |
186 |
180 |
$16K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
156 |
76 |
$15K |
| D0120 |
Periodic oral evaluation - established patient |
358 |
328 |
$8K |
| D1320 |
|
94 |
92 |
$3K |
| D0330 |
Panoramic radiographic image |
212 |
154 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
216 |
194 |
$1K |
| D0274 |
Bitewings - four radiographic images |
41 |
41 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
192 |
93 |
$1K |
| D1120 |
Prophylaxis - child |
13 |
13 |
$496.86 |