| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
552 |
550 |
$18K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
238 |
160 |
$14K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
253 |
170 |
$12K |
| D0274 |
Bitewings - four radiographic images |
375 |
373 |
$10K |
| D0330 |
Panoramic radiographic image |
210 |
208 |
$8K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
345 |
343 |
$6K |
| D0120 |
Periodic oral evaluation - established patient |
306 |
306 |
$6K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
62 |
42 |
$4K |
| D1330 |
|
309 |
309 |
$3K |
| D1206 |
Topical application of fluoride varnish |
80 |
80 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
12 |
12 |
$68.00 |