| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,964 |
800 |
$122K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,401 |
755 |
$111K |
| D1110 |
Prophylaxis - adult |
1,705 |
1,664 |
$57K |
| D0140 |
Limited oral evaluation - problem focused |
925 |
881 |
$19K |
| D0330 |
Panoramic radiographic image |
497 |
483 |
$19K |
| D0120 |
Periodic oral evaluation - established patient |
1,190 |
1,162 |
$18K |
| D0274 |
Bitewings - four radiographic images |
673 |
656 |
$12K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
370 |
360 |
$7K |
| D0220 |
Intraoral - periapical first radiographic image |
672 |
649 |
$5K |
| D2331 |
|
37 |
19 |
$2K |
| D2330 |
|
19 |
13 |
$742.00 |