| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
2,191 |
1,173 |
$158K |
| D1110 |
Prophylaxis - adult |
2,957 |
2,951 |
$132K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
3,538 |
3,535 |
$123K |
| D0274 |
Bitewings - four radiographic images |
3,252 |
3,247 |
$94K |
| D1208 |
Topical application of fluoride, excluding varnish |
4,291 |
4,285 |
$78K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
889 |
525 |
$76K |
| D1120 |
Prophylaxis - child |
1,763 |
1,762 |
$56K |
| D0210 |
Intraoral - complete series of radiographic images |
721 |
715 |
$43K |
| D0120 |
Periodic oral evaluation - established patient |
803 |
803 |
$18K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
302 |
194 |
$16K |
| D0220 |
Intraoral - periapical first radiographic image |
880 |
869 |
$10K |
| D0140 |
Limited oral evaluation - problem focused |
242 |
240 |
$7K |
| D0330 |
Panoramic radiographic image |
84 |
84 |
$3K |
| D4346 |
|
13 |
13 |
$2K |
| D0272 |
Bitewings - two radiographic images |
12 |
12 |
$243.62 |