| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
192 |
110 |
$23K |
| D0120 |
Periodic oral evaluation - established patient |
801 |
800 |
$21K |
| D1110 |
Prophylaxis - adult |
299 |
299 |
$15K |
| D1120 |
Prophylaxis - child |
411 |
410 |
$15K |
| D1208 |
Topical application of fluoride, excluding varnish |
513 |
512 |
$11K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
31 |
25 |
$4K |
| D0274 |
Bitewings - four radiographic images |
65 |
65 |
$2K |
| D0272 |
Bitewings - two radiographic images |
90 |
90 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
57 |
54 |
$956.00 |
| D0330 |
Panoramic radiographic image |
16 |
16 |
$867.89 |
| D0140 |
Limited oral evaluation - problem focused |
13 |
13 |
$572.00 |