| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
924 |
612 |
$109K |
| D1110 |
Prophylaxis - adult |
1,410 |
1,410 |
$61K |
| D2750 |
|
74 |
69 |
$55K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
600 |
374 |
$48K |
| D0120 |
Periodic oral evaluation - established patient |
945 |
945 |
$20K |
| D0274 |
Bitewings - four radiographic images |
921 |
921 |
$20K |
| D0220 |
Intraoral - periapical first radiographic image |
1,758 |
1,750 |
$18K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,569 |
1,568 |
$18K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
529 |
529 |
$12K |
| D0210 |
Intraoral - complete series of radiographic images |
412 |
412 |
$6K |
| D2954 |
|
14 |
14 |
$2K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
13 |
12 |
$1K |
| D2330 |
|
24 |
12 |
$1K |
| D1208 |
Topical application of fluoride, excluding varnish |
13 |
13 |
$141.70 |