| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
109 |
52 |
$16K |
| D0330 |
Panoramic radiographic image |
147 |
124 |
$12K |
| D1206 |
Topical application of fluoride varnish |
435 |
365 |
$11K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
68 |
24 |
$9K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
79 |
68 |
$4K |
| D0274 |
Bitewings - four radiographic images |
55 |
55 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
49 |
43 |
$3K |
| D1110 |
Prophylaxis - adult |
13 |
13 |
$1K |
| D0120 |
Periodic oral evaluation - established patient |
14 |
14 |
$635.18 |
| D0220 |
Intraoral - periapical first radiographic image |
13 |
12 |
$317.59 |