| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
974 |
475 |
$100K |
| D1110 |
Prophylaxis - adult |
2,014 |
1,996 |
$99K |
| D0330 |
Panoramic radiographic image |
1,079 |
1,074 |
$65K |
| D0120 |
Periodic oral evaluation - established patient |
2,211 |
2,191 |
$63K |
| D0272 |
Bitewings - two radiographic images |
1,214 |
1,211 |
$26K |
| D1208 |
Topical application of fluoride, excluding varnish |
969 |
957 |
$21K |
| D1120 |
Prophylaxis - child |
618 |
607 |
$21K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
289 |
160 |
$19K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
342 |
335 |
$16K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
38 |
25 |
$5K |
| D1351 |
Sealant - per tooth |
40 |
12 |
$1K |