| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
776 |
413 |
$48K |
| D1110 |
Prophylaxis - adult |
679 |
669 |
$34K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
452 |
267 |
$34K |
| D0330 |
Panoramic radiographic image |
351 |
343 |
$24K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
821 |
785 |
$22K |
| D0274 |
Bitewings - four radiographic images |
652 |
622 |
$19K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
303 |
196 |
$15K |
| D2332 |
|
72 |
42 |
$5K |
| D1208 |
Topical application of fluoride, excluding varnish |
244 |
238 |
$4K |
| D2331 |
|
55 |
42 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
310 |
300 |
$3K |
| D1120 |
Prophylaxis - child |
52 |
52 |
$2K |
| D2335 |
|
19 |
12 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
13 |
13 |
$384.76 |
| D0120 |
Periodic oral evaluation - established patient |
13 |
13 |
$357.50 |
| D0230 |
Intraoral - periapical each additional radiographic image |
17 |
14 |
$126.75 |