| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
816 |
350 |
$38K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
473 |
238 |
$30K |
| D1110 |
Prophylaxis - adult |
1,267 |
1,040 |
$22K |
| D0274 |
Bitewings - four radiographic images |
1,193 |
970 |
$16K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
911 |
686 |
$16K |
| D0330 |
Panoramic radiographic image |
835 |
651 |
$15K |
| D0120 |
Periodic oral evaluation - established patient |
642 |
535 |
$7K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
106 |
64 |
$5K |
| D0140 |
Limited oral evaluation - problem focused |
347 |
277 |
$5K |
| D2394 |
|
48 |
25 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
313 |
230 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
51 |
39 |
$558.70 |
| D1208 |
Topical application of fluoride, excluding varnish |
22 |
19 |
$329.38 |