| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
1,177 |
148 |
$96K |
| D0330 |
Panoramic radiographic image |
592 |
514 |
$21K |
| D1110 |
Prophylaxis - adult |
675 |
598 |
$11K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
617 |
142 |
$8K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
608 |
528 |
$3K |
| D2332 |
|
1,269 |
137 |
$2K |
| D1330 |
|
726 |
653 |
$145.85 |
| D0274 |
Bitewings - four radiographic images |
158 |
119 |
$102.90 |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
31 |
13 |
$93.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
158 |
118 |
$0.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
14 |
14 |
$0.00 |
| D0220 |
Intraoral - periapical first radiographic image |
186 |
141 |
$0.00 |