| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
355 |
176 |
$35K |
| D0120 |
Periodic oral evaluation - established patient |
1,270 |
1,270 |
$29K |
| D1110 |
Prophylaxis - adult |
544 |
544 |
$27K |
| D1120 |
Prophylaxis - child |
701 |
701 |
$24K |
| D1206 |
Topical application of fluoride varnish |
1,388 |
1,388 |
$22K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
127 |
52 |
$16K |
| D0272 |
Bitewings - two radiographic images |
507 |
507 |
$10K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
55 |
31 |
$4K |
| D0330 |
Panoramic radiographic image |
57 |
57 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
80 |
69 |
$3K |