| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
521 |
234 |
$71K |
| D1110 |
Prophylaxis - adult |
611 |
605 |
$40K |
| D2750 |
|
73 |
40 |
$35K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
326 |
153 |
$35K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
410 |
402 |
$23K |
| D0330 |
Panoramic radiographic image |
350 |
344 |
$16K |
| D1208 |
Topical application of fluoride, excluding varnish |
591 |
586 |
$14K |
| D0120 |
Periodic oral evaluation - established patient |
315 |
315 |
$10K |
| D0274 |
Bitewings - four radiographic images |
346 |
342 |
$8K |
| D2950 |
|
44 |
28 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
326 |
312 |
$4K |
| D0140 |
Limited oral evaluation - problem focused |
39 |
37 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
124 |
119 |
$806.88 |