| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
424 |
181 |
$41K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
498 |
231 |
$37K |
| D1110 |
Prophylaxis - adult |
455 |
455 |
$25K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
513 |
513 |
$15K |
| D0330 |
Panoramic radiographic image |
412 |
412 |
$14K |
| D0120 |
Periodic oral evaluation - established patient |
403 |
402 |
$11K |
| D1120 |
Prophylaxis - child |
173 |
173 |
$7K |
| D1206 |
Topical application of fluoride varnish |
364 |
364 |
$4K |
| D0274 |
Bitewings - four radiographic images |
354 |
354 |
$4K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
41 |
24 |
$3K |
| D2332 |
|
30 |
13 |
$3K |