| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
455 |
171 |
$32K |
| D1110 |
Prophylaxis - adult |
394 |
391 |
$12K |
| D1206 |
Topical application of fluoride varnish |
641 |
594 |
$12K |
| D0120 |
Periodic oral evaluation - established patient |
640 |
635 |
$10K |
| D0274 |
Bitewings - four radiographic images |
448 |
439 |
$10K |
| D0220 |
Intraoral - periapical first radiographic image |
852 |
794 |
$7K |
| D0230 |
Intraoral - periapical each additional radiographic image |
796 |
635 |
$7K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
153 |
149 |
$4K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
65 |
29 |
$4K |
| D0330 |
Panoramic radiographic image |
47 |
47 |
$863.84 |
| D1120 |
Prophylaxis - child |
25 |
25 |
$838.00 |