| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
243 |
145 |
$19K |
| D1110 |
Prophylaxis - adult |
264 |
264 |
$15K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
68 |
53 |
$6K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
192 |
192 |
$6K |
| D0330 |
Panoramic radiographic image |
129 |
129 |
$5K |
| D0120 |
Periodic oral evaluation - established patient |
164 |
164 |
$5K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
78 |
47 |
$4K |
| D0274 |
Bitewings - four radiographic images |
147 |
147 |
$4K |
| D1120 |
Prophylaxis - child |
71 |
71 |
$3K |
| D0210 |
Intraoral - complete series of radiographic images |
26 |
26 |
$1K |
| D1208 |
Topical application of fluoride, excluding varnish |
96 |
96 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
14 |
14 |
$212.55 |