| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
990 |
434 |
$70K |
| D1110 |
Prophylaxis - adult |
1,115 |
1,039 |
$56K |
| D0274 |
Bitewings - four radiographic images |
767 |
717 |
$27K |
| D0120 |
Periodic oral evaluation - established patient |
1,003 |
926 |
$24K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
364 |
341 |
$13K |
| D0330 |
Panoramic radiographic image |
190 |
177 |
$10K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
142 |
88 |
$9K |
| D0210 |
Intraoral - complete series of radiographic images |
251 |
214 |
$8K |
| D1208 |
Topical application of fluoride, excluding varnish |
402 |
385 |
$6K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
42 |
27 |
$4K |
| D1206 |
Topical application of fluoride varnish |
80 |
64 |
$1K |
| D1120 |
Prophylaxis - child |
25 |
25 |
$828.00 |