| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
73 |
44 |
$4K |
| D1110 |
Prophylaxis - adult |
105 |
105 |
$4K |
| D0120 |
Periodic oral evaluation - established patient |
73 |
73 |
$2K |
| D0274 |
Bitewings - four radiographic images |
68 |
68 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
38 |
38 |
$1K |
| D0330 |
Panoramic radiographic image |
24 |
24 |
$887.63 |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
16 |
12 |
$867.10 |
| D1208 |
Topical application of fluoride, excluding varnish |
22 |
22 |
$430.92 |
| D0220 |
Intraoral - periapical first radiographic image |
26 |
26 |
$219.12 |
| D1330 |
|
13 |
13 |
$84.23 |