| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
153 |
101 |
$8K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
92 |
56 |
$5K |
| D1110 |
Prophylaxis - adult |
100 |
95 |
$3K |
| D0120 |
Periodic oral evaluation - established patient |
148 |
146 |
$2K |
| D8030 |
|
16 |
15 |
$1K |
| D0274 |
Bitewings - four radiographic images |
62 |
61 |
$1K |
| D1208 |
Topical application of fluoride, excluding varnish |
56 |
55 |
$802.50 |
| D0210 |
Intraoral - complete series of radiographic images |
12 |
12 |
$693.00 |
| D0330 |
Panoramic radiographic image |
12 |
12 |
$535.04 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
12 |
12 |
$332.04 |
| D1120 |
Prophylaxis - child |
12 |
12 |
$252.00 |