| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
1,410 |
422 |
$89K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,864 |
1,043 |
$35K |
| D2394 |
|
494 |
110 |
$32K |
| D1120 |
Prophylaxis - child |
1,763 |
1,004 |
$24K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
582 |
141 |
$20K |
| D1206 |
Topical application of fluoride varnish |
1,546 |
920 |
$18K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
314 |
117 |
$15K |
| D0272 |
Bitewings - two radiographic images |
1,233 |
700 |
$10K |
| D0330 |
Panoramic radiographic image |
525 |
298 |
$9K |
| D0274 |
Bitewings - four radiographic images |
281 |
131 |
$3K |
| D0210 |
Intraoral - complete series of radiographic images |
113 |
31 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
57 |
25 |
$265.87 |