| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,985 |
834 |
$398K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
651 |
358 |
$110K |
| D1110 |
Prophylaxis - adult |
1,106 |
993 |
$62K |
| D0274 |
Bitewings - four radiographic images |
845 |
734 |
$32K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
653 |
548 |
$31K |
| D0330 |
Panoramic radiographic image |
411 |
368 |
$23K |
| D0120 |
Periodic oral evaluation - established patient |
268 |
243 |
$10K |
| D1208 |
Topical application of fluoride, excluding varnish |
130 |
116 |
$4K |
| D0603 |
|
27 |
21 |
$0.00 |
| D0602 |
|
15 |
14 |
$0.00 |