| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,238 |
493 |
$150K |
| D1110 |
Prophylaxis - adult |
1,211 |
1,205 |
$61K |
| D0120 |
Periodic oral evaluation - established patient |
1,980 |
1,976 |
$52K |
| D1120 |
Prophylaxis - child |
1,156 |
1,156 |
$43K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,495 |
1,494 |
$34K |
| D0274 |
Bitewings - four radiographic images |
707 |
703 |
$23K |
| D0220 |
Intraoral - periapical first radiographic image |
1,306 |
1,285 |
$20K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,532 |
1,073 |
$14K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
77 |
77 |
$3K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
16 |
14 |
$3K |
| D0330 |
Panoramic radiographic image |
19 |
19 |
$720.00 |