| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,128 |
344 |
$51K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
655 |
332 |
$30K |
| D1110 |
Prophylaxis - adult |
936 |
858 |
$28K |
| D0330 |
Panoramic radiographic image |
355 |
325 |
$14K |
| D0274 |
Bitewings - four radiographic images |
681 |
632 |
$12K |
| D0120 |
Periodic oral evaluation - established patient |
724 |
680 |
$11K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
431 |
377 |
$10K |
| D1208 |
Topical application of fluoride, excluding varnish |
474 |
447 |
$6K |
| D1120 |
Prophylaxis - child |
213 |
196 |
$4K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
41 |
30 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
211 |
193 |
$835.00 |
| D0350 |
|
63 |
57 |
$689.36 |
| D0272 |
Bitewings - two radiographic images |
31 |
25 |
$240.00 |
| D1206 |
Topical application of fluoride varnish |
15 |
13 |
$180.00 |
| D1999 |
|
49 |
42 |
$0.00 |