| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
282 |
191 |
$37K |
| D0330 |
Panoramic radiographic image |
367 |
363 |
$25K |
| D0120 |
Periodic oral evaluation - established patient |
676 |
646 |
$23K |
| D1110 |
Prophylaxis - adult |
355 |
352 |
$21K |
| D1120 |
Prophylaxis - child |
463 |
460 |
$21K |
| D1208 |
Topical application of fluoride, excluding varnish |
504 |
498 |
$13K |
| D0272 |
Bitewings - two radiographic images |
358 |
353 |
$9K |
| D1206 |
Topical application of fluoride varnish |
156 |
156 |
$5K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
50 |
42 |
$5K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
13 |
12 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
58 |
55 |
$1K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
14 |
14 |
$897.82 |