| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
665 |
243 |
$56K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,527 |
461 |
$42K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
878 |
274 |
$33K |
| D1110 |
Prophylaxis - adult |
934 |
921 |
$15K |
| D0330 |
Panoramic radiographic image |
528 |
522 |
$12K |
| D0120 |
Periodic oral evaluation - established patient |
626 |
621 |
$11K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
485 |
480 |
$6K |
| D2332 |
|
68 |
28 |
$4K |
| D0274 |
Bitewings - four radiographic images |
969 |
957 |
$1K |
| D1330 |
|
1,009 |
999 |
$841.91 |
| D1120 |
Prophylaxis - child |
115 |
114 |
$660.04 |
| D1208 |
Topical application of fluoride, excluding varnish |
1,096 |
1,082 |
$599.68 |
| D0140 |
Limited oral evaluation - problem focused |
335 |
318 |
$267.74 |
| D0220 |
Intraoral - periapical first radiographic image |
584 |
576 |
$236.65 |
| D0230 |
Intraoral - periapical each additional radiographic image |
571 |
563 |
$92.60 |
| D0272 |
Bitewings - two radiographic images |
12 |
12 |
$0.00 |