| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
300 |
132 |
$40K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
399 |
390 |
$22K |
| D1110 |
Prophylaxis - adult |
330 |
321 |
$21K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
154 |
78 |
$16K |
| D0330 |
Panoramic radiographic image |
313 |
306 |
$14K |
| D1206 |
Topical application of fluoride varnish |
491 |
485 |
$13K |
| D0274 |
Bitewings - four radiographic images |
406 |
400 |
$10K |
| D0220 |
Intraoral - periapical first radiographic image |
571 |
538 |
$6K |
| D0120 |
Periodic oral evaluation - established patient |
177 |
177 |
$6K |
| D0230 |
Intraoral - periapical each additional radiographic image |
443 |
435 |
$3K |