| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
348 |
253 |
$68K |
| D1206 |
Topical application of fluoride varnish |
839 |
839 |
$36K |
| D1120 |
Prophylaxis - child |
649 |
649 |
$35K |
| D0330 |
Panoramic radiographic image |
198 |
198 |
$19K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
261 |
261 |
$18K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
127 |
83 |
$17K |
| D1351 |
Sealant - per tooth |
338 |
108 |
$16K |
| D0272 |
Bitewings - two radiographic images |
366 |
366 |
$12K |
| D1110 |
Prophylaxis - adult |
145 |
145 |
$10K |
| D0120 |
Periodic oral evaluation - established patient |
277 |
277 |
$10K |
| D0274 |
Bitewings - four radiographic images |
117 |
117 |
$5K |