| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0330 |
Panoramic radiographic image |
264 |
262 |
$12K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
211 |
125 |
$11K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
420 |
418 |
$10K |
| D1110 |
Prophylaxis - adult |
193 |
191 |
$6K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
92 |
58 |
$6K |
| D0120 |
Periodic oral evaluation - established patient |
93 |
93 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
58 |
58 |
$870.00 |
| D1120 |
Prophylaxis - child |
33 |
33 |
$660.00 |
| D0274 |
Bitewings - four radiographic images |
28 |
28 |
$560.00 |