| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
685 |
314 |
$44K |
| D2335 |
|
373 |
141 |
$35K |
| D1110 |
Prophylaxis - adult |
1,030 |
1,017 |
$34K |
| D0330 |
Panoramic radiographic image |
691 |
683 |
$30K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
479 |
210 |
$24K |
| D0120 |
Periodic oral evaluation - established patient |
1,336 |
1,315 |
$22K |
| D0274 |
Bitewings - four radiographic images |
1,064 |
1,049 |
$20K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
541 |
536 |
$14K |
| D2161 |
|
139 |
78 |
$10K |
| D1208 |
Topical application of fluoride, excluding varnish |
442 |
432 |
$6K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
118 |
60 |
$6K |
| D2332 |
|
219 |
89 |
$5K |
| D1120 |
Prophylaxis - child |
65 |
65 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
160 |
150 |
$780.00 |