| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
309 |
174 |
$17K |
| D1110 |
Prophylaxis - adult |
450 |
415 |
$16K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
155 |
93 |
$9K |
| D0120 |
Periodic oral evaluation - established patient |
442 |
416 |
$7K |
| D0274 |
Bitewings - four radiographic images |
339 |
311 |
$7K |
| D0330 |
Panoramic radiographic image |
151 |
143 |
$5K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
110 |
71 |
$5K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
167 |
156 |
$4K |
| D1120 |
Prophylaxis - child |
86 |
81 |
$4K |
| D1206 |
Topical application of fluoride varnish |
229 |
221 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
75 |
68 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
315 |
273 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
187 |
116 |
$768.00 |