| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,559 |
950 |
$118K |
| D1110 |
Prophylaxis - adult |
2,063 |
2,061 |
$102K |
| D0274 |
Bitewings - four radiographic images |
1,984 |
1,984 |
$55K |
| D0120 |
Periodic oral evaluation - established patient |
2,182 |
2,180 |
$52K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
345 |
249 |
$34K |
| D2752 |
|
62 |
40 |
$33K |
| D1120 |
Prophylaxis - child |
463 |
463 |
$19K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
505 |
505 |
$15K |
| D1208 |
Topical application of fluoride, excluding varnish |
791 |
791 |
$11K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
154 |
99 |
$8K |
| D0220 |
Intraoral - periapical first radiographic image |
478 |
473 |
$6K |
| D0210 |
Intraoral - complete series of radiographic images |
243 |
243 |
$6K |
| D0140 |
Limited oral evaluation - problem focused |
167 |
165 |
$2K |
| D0330 |
Panoramic radiographic image |
57 |
57 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
12 |
12 |
$92.54 |