| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
532 |
200 |
$49K |
| D1110 |
Prophylaxis - adult |
362 |
324 |
$12K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
336 |
308 |
$12K |
| D0330 |
Panoramic radiographic image |
267 |
251 |
$10K |
| D1206 |
Topical application of fluoride varnish |
311 |
300 |
$7K |
| D1120 |
Prophylaxis - child |
159 |
153 |
$6K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
58 |
39 |
$6K |
| D0140 |
Limited oral evaluation - problem focused |
261 |
236 |
$6K |
| D0274 |
Bitewings - four radiographic images |
344 |
313 |
$5K |
| D0120 |
Periodic oral evaluation - established patient |
245 |
222 |
$4K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
20 |
12 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
208 |
179 |
$1K |
| D1330 |
|
77 |
73 |
$432.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
16 |
15 |
$238.00 |