| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
468 |
302 |
$65K |
| D1110 |
Prophylaxis - adult |
1,221 |
1,196 |
$62K |
| D0120 |
Periodic oral evaluation - established patient |
1,195 |
1,164 |
$32K |
| D0274 |
Bitewings - four radiographic images |
904 |
888 |
$29K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
484 |
476 |
$21K |
| D0330 |
Panoramic radiographic image |
287 |
279 |
$15K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
130 |
84 |
$14K |
| D4910 |
|
109 |
106 |
$8K |
| D0220 |
Intraoral - periapical first radiographic image |
309 |
305 |
$4K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
14 |
13 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
102 |
101 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
41 |
40 |
$1K |