| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,121 |
1,080 |
$45K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
540 |
271 |
$44K |
| D0274 |
Bitewings - four radiographic images |
736 |
711 |
$13K |
| D0120 |
Periodic oral evaluation - established patient |
687 |
663 |
$12K |
| D0330 |
Panoramic radiographic image |
309 |
298 |
$11K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
140 |
72 |
$10K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
324 |
318 |
$10K |
| D0220 |
Intraoral - periapical first radiographic image |
615 |
590 |
$4K |
| D0140 |
Limited oral evaluation - problem focused |
147 |
142 |
$4K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
18 |
14 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
16 |
14 |
$261.00 |