| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
216 |
65 |
$14K |
| D1110 |
Prophylaxis - adult |
270 |
236 |
$12K |
| D0120 |
Periodic oral evaluation - established patient |
258 |
213 |
$5K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
172 |
148 |
$5K |
| D1208 |
Topical application of fluoride, excluding varnish |
427 |
361 |
$5K |
| D0274 |
Bitewings - four radiographic images |
172 |
153 |
$4K |
| D1120 |
Prophylaxis - child |
57 |
51 |
$1K |
| D0272 |
Bitewings - two radiographic images |
44 |
42 |
$862.72 |
| D0330 |
Panoramic radiographic image |
15 |
13 |
$474.25 |
| D0602 |
|
348 |
327 |
$71.00 |
| D0601 |
|
32 |
30 |
$5.00 |
| D0603 |
|
103 |
88 |
$0.00 |
| D1330 |
|
14 |
14 |
$0.00 |