| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
347 |
130 |
$19K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
467 |
216 |
$17K |
| D0330 |
Panoramic radiographic image |
337 |
334 |
$12K |
| D1110 |
Prophylaxis - adult |
238 |
236 |
$6K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
278 |
150 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
406 |
403 |
$2K |
| D0120 |
Periodic oral evaluation - established patient |
60 |
58 |
$1K |
| D0350 |
|
147 |
31 |
$684.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
281 |
276 |
$449.33 |
| D0274 |
Bitewings - four radiographic images |
95 |
90 |
$339.73 |
| D0230 |
Intraoral - periapical each additional radiographic image |
109 |
76 |
$88.51 |
| D0220 |
Intraoral - periapical first radiographic image |
104 |
98 |
$41.23 |
| D1330 |
|
128 |
128 |
$30.00 |