| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
292 |
143 |
$25K |
| D1110 |
Prophylaxis - adult |
559 |
552 |
$18K |
| D0274 |
Bitewings - four radiographic images |
327 |
324 |
$5K |
| D0120 |
Periodic oral evaluation - established patient |
326 |
321 |
$5K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
34 |
26 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
100 |
99 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
263 |
259 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
273 |
174 |
$1K |