| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
498 |
236 |
$57K |
| D1110 |
Prophylaxis - adult |
673 |
673 |
$30K |
| D0120 |
Periodic oral evaluation - established patient |
847 |
847 |
$19K |
| D0330 |
Panoramic radiographic image |
317 |
316 |
$18K |
| D1206 |
Topical application of fluoride varnish |
806 |
805 |
$17K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
334 |
332 |
$15K |
| D1120 |
Prophylaxis - child |
457 |
456 |
$15K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
82 |
44 |
$13K |
| D0274 |
Bitewings - four radiographic images |
334 |
334 |
$9K |
| D0220 |
Intraoral - periapical first radiographic image |
429 |
427 |
$6K |
| D0230 |
Intraoral - periapical each additional radiographic image |
372 |
363 |
$3K |
| D0210 |
Intraoral - complete series of radiographic images |
36 |
35 |
$2K |