| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
1,008 |
193 |
$80K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
663 |
152 |
$44K |
| D2330 |
|
484 |
138 |
$37K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
537 |
537 |
$35K |
| D0210 |
Intraoral - complete series of radiographic images |
418 |
417 |
$20K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
274 |
77 |
$15K |
| D0350 |
|
384 |
312 |
$12K |
| D1110 |
Prophylaxis - adult |
95 |
95 |
$9K |
| D0330 |
Panoramic radiographic image |
110 |
110 |
$3K |
| D0340 |
|
51 |
51 |
$3K |
| D1206 |
Topical application of fluoride varnish |
156 |
154 |
$3K |
| D9430 |
|
50 |
46 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
80 |
56 |
$618.64 |
| D1320 |
|
35 |
35 |
$532.50 |
| D0274 |
Bitewings - four radiographic images |
14 |
14 |
$259.20 |
| D1208 |
Topical application of fluoride, excluding varnish |
16 |
16 |
$228.00 |
| D9995 |
|
26 |
24 |
$82.08 |