| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
622 |
246 |
$24K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
655 |
229 |
$18K |
| D0210 |
Intraoral - complete series of radiographic images |
644 |
636 |
$14K |
| D1110 |
Prophylaxis - adult |
421 |
415 |
$9K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
701 |
692 |
$9K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
220 |
74 |
$8K |
| D0330 |
Panoramic radiographic image |
455 |
449 |
$5K |
| D1208 |
Topical application of fluoride, excluding varnish |
455 |
444 |
$4K |
| D1330 |
|
708 |
697 |
$2K |
| D2332 |
|
34 |
12 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
14 |
14 |
$95.30 |
| D0220 |
Intraoral - periapical first radiographic image |
13 |
13 |
$49.02 |