| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
2,098 |
366 |
$132K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,295 |
288 |
$59K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
454 |
179 |
$34K |
| D2330 |
|
548 |
130 |
$26K |
| D1110 |
Prophylaxis - adult |
425 |
424 |
$17K |
| D2335 |
|
146 |
40 |
$13K |
| D0120 |
Periodic oral evaluation - established patient |
430 |
429 |
$9K |
| D0330 |
Panoramic radiographic image |
300 |
298 |
$9K |
| D0230 |
Intraoral - periapical each additional radiographic image |
113 |
61 |
$1K |
| D0274 |
Bitewings - four radiographic images |
31 |
31 |
$550.70 |