| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
164 |
76 |
$7K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
120 |
51 |
$6K |
| D0330 |
Panoramic radiographic image |
80 |
80 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
102 |
102 |
$2K |
| D4341 |
|
47 |
15 |
$903.24 |
| D1206 |
Topical application of fluoride varnish |
42 |
42 |
$570.46 |
| D0274 |
Bitewings - four radiographic images |
53 |
53 |
$501.58 |
| D0230 |
Intraoral - periapical each additional radiographic image |
171 |
66 |
$481.55 |
| D1330 |
|
85 |
85 |
$456.98 |
| D0220 |
Intraoral - periapical first radiographic image |
76 |
71 |
$246.88 |