| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
454 |
129 |
$37K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
267 |
63 |
$17K |
| D0160 |
|
171 |
131 |
$9K |
| D1110 |
Prophylaxis - adult |
226 |
186 |
$7K |
| D0120 |
Periodic oral evaluation - established patient |
290 |
233 |
$6K |
| D0274 |
Bitewings - four radiographic images |
202 |
166 |
$5K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
68 |
34 |
$5K |
| D0330 |
Panoramic radiographic image |
120 |
90 |
$4K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
116 |
91 |
$4K |
| D1208 |
Topical application of fluoride, excluding varnish |
266 |
209 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
261 |
209 |
$3K |
| D1120 |
Prophylaxis - child |
140 |
108 |
$3K |
| D4355 |
|
48 |
37 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
259 |
185 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
47 |
30 |
$1K |
| D0272 |
Bitewings - two radiographic images |
18 |
15 |
$270.90 |