| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
717 |
460 |
$51K |
| D1110 |
Prophylaxis - adult |
1,282 |
1,265 |
$51K |
| D0120 |
Periodic oral evaluation - established patient |
1,693 |
1,670 |
$33K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
545 |
342 |
$31K |
| D0274 |
Bitewings - four radiographic images |
866 |
859 |
$26K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
310 |
234 |
$25K |
| D0330 |
Panoramic radiographic image |
386 |
385 |
$17K |
| D1120 |
Prophylaxis - child |
410 |
405 |
$12K |
| D1351 |
Sealant - per tooth |
479 |
149 |
$12K |
| D1208 |
Topical application of fluoride, excluding varnish |
645 |
635 |
$12K |
| D9110 |
|
173 |
171 |
$6K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
229 |
229 |
$6K |
| D0272 |
Bitewings - two radiographic images |
189 |
187 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
341 |
337 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
18 |
15 |
$197.00 |
| D1999 |
|
17 |
17 |
$0.00 |