| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,542 |
603 |
$78K |
| D0330 |
Panoramic radiographic image |
1,702 |
1,702 |
$76K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
949 |
483 |
$73K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
499 |
284 |
$48K |
| D0274 |
Bitewings - four radiographic images |
1,507 |
1,505 |
$43K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,471 |
1,471 |
$41K |
| D1110 |
Prophylaxis - adult |
717 |
717 |
$39K |
| D0120 |
Periodic oral evaluation - established patient |
1,415 |
1,413 |
$38K |
| D2330 |
|
502 |
232 |
$27K |
| D0230 |
Intraoral - periapical each additional radiographic image |
706 |
704 |
$24K |
| D1120 |
Prophylaxis - child |
266 |
266 |
$11K |
| D0220 |
Intraoral - periapical first radiographic image |
456 |
452 |
$6K |
| D0272 |
Bitewings - two radiographic images |
283 |
283 |
$6K |
| D1208 |
Topical application of fluoride, excluding varnish |
406 |
406 |
$6K |
| D0140 |
Limited oral evaluation - problem focused |
244 |
244 |
$4K |
| D1206 |
Topical application of fluoride varnish |
13 |
13 |
$370.50 |