| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2394 |
|
40 |
25 |
$8K |
| D1110 |
Prophylaxis - adult |
187 |
186 |
$7K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
27 |
14 |
$4K |
| D0120 |
Periodic oral evaluation - established patient |
177 |
177 |
$4K |
| D0274 |
Bitewings - four radiographic images |
126 |
126 |
$4K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
25 |
15 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
55 |
54 |
$2K |
| D0330 |
Panoramic radiographic image |
12 |
12 |
$597.36 |
| D1206 |
Topical application of fluoride varnish |
25 |
25 |
$404.68 |