| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
320 |
152 |
$24K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
614 |
614 |
$21K |
| D0210 |
Intraoral - complete series of radiographic images |
264 |
264 |
$14K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
204 |
122 |
$11K |
| D1120 |
Prophylaxis - child |
298 |
298 |
$9K |
| D1206 |
Topical application of fluoride varnish |
267 |
267 |
$5K |
| D4346 |
|
38 |
38 |
$4K |
| D0274 |
Bitewings - four radiographic images |
138 |
138 |
$4K |
| D1110 |
Prophylaxis - adult |
69 |
69 |
$3K |
| D0120 |
Periodic oral evaluation - established patient |
126 |
126 |
$3K |
| D0330 |
Panoramic radiographic image |
26 |
26 |
$944.09 |
| D0140 |
Limited oral evaluation - problem focused |
27 |
26 |
$743.23 |
| D0220 |
Intraoral - periapical first radiographic image |
39 |
38 |
$408.06 |