| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,048 |
605 |
$71K |
| D1110 |
Prophylaxis - adult |
1,264 |
1,115 |
$45K |
| D0120 |
Periodic oral evaluation - established patient |
1,239 |
1,105 |
$26K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
243 |
177 |
$18K |
| D0274 |
Bitewings - four radiographic images |
746 |
672 |
$16K |
| D1208 |
Topical application of fluoride, excluding varnish |
522 |
500 |
$10K |
| D1120 |
Prophylaxis - child |
240 |
231 |
$7K |
| D0330 |
Panoramic radiographic image |
179 |
160 |
$6K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
241 |
220 |
$6K |
| D0220 |
Intraoral - periapical first radiographic image |
498 |
433 |
$5K |
| D0140 |
Limited oral evaluation - problem focused |
101 |
89 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
69 |
43 |
$551.60 |
| D2950 |
|
15 |
12 |
$532.28 |