| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
415 |
267 |
$28K |
| D1110 |
Prophylaxis - adult |
358 |
358 |
$26K |
| D0120 |
Periodic oral evaluation - established patient |
598 |
598 |
$23K |
| D1120 |
Prophylaxis - child |
400 |
400 |
$12K |
| D0274 |
Bitewings - four radiographic images |
531 |
528 |
$11K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
197 |
195 |
$9K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,770 |
781 |
$7K |
| D0350 |
|
593 |
333 |
$5K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
71 |
57 |
$5K |
| D1208 |
Topical application of fluoride, excluding varnish |
381 |
381 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
293 |
287 |
$3K |
| D0210 |
Intraoral - complete series of radiographic images |
74 |
74 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
34 |
25 |
$2K |
| D9430 |
|
37 |
37 |
$1K |