| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
128 |
65 |
$10K |
| D1110 |
Prophylaxis - adult |
174 |
174 |
$9K |
| D0274 |
Bitewings - four radiographic images |
218 |
218 |
$7K |
| D0120 |
Periodic oral evaluation - established patient |
209 |
208 |
$6K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
41 |
28 |
$4K |
| D1120 |
Prophylaxis - child |
98 |
98 |
$4K |
| D0330 |
Panoramic radiographic image |
74 |
74 |
$3K |
| D1208 |
Topical application of fluoride, excluding varnish |
115 |
115 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
41 |
41 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
42 |
40 |
$568.15 |