| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
341 |
120 |
$43K |
| D1110 |
Prophylaxis - adult |
667 |
650 |
$43K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
236 |
101 |
$40K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
398 |
382 |
$22K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
196 |
69 |
$19K |
| D0330 |
Panoramic radiographic image |
365 |
350 |
$16K |
| D1208 |
Topical application of fluoride, excluding varnish |
680 |
663 |
$16K |
| D0274 |
Bitewings - four radiographic images |
532 |
518 |
$12K |
| D0120 |
Periodic oral evaluation - established patient |
283 |
283 |
$9K |
| D0220 |
Intraoral - periapical first radiographic image |
14 |
14 |
$165.48 |
| D1330 |
|
15 |
15 |
$78.00 |