| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
279 |
141 |
$31K |
| D1110 |
Prophylaxis - adult |
463 |
456 |
$18K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
386 |
371 |
$17K |
| D0330 |
Panoramic radiographic image |
359 |
349 |
$15K |
| D0274 |
Bitewings - four radiographic images |
360 |
354 |
$11K |
| D0120 |
Periodic oral evaluation - established patient |
387 |
375 |
$9K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
70 |
39 |
$8K |
| D1208 |
Topical application of fluoride, excluding varnish |
169 |
163 |
$3K |
| D1120 |
Prophylaxis - child |
88 |
85 |
$2K |