| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
354 |
176 |
$33K |
| D1110 |
Prophylaxis - adult |
509 |
508 |
$26K |
| D2394 |
|
209 |
104 |
$25K |
| D0120 |
Periodic oral evaluation - established patient |
895 |
894 |
$23K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
210 |
105 |
$15K |
| D0274 |
Bitewings - four radiographic images |
109 |
109 |
$3K |
| D0210 |
Intraoral - complete series of radiographic images |
33 |
33 |
$2K |
| D0330 |
Panoramic radiographic image |
42 |
42 |
$1K |