| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
75 |
36 |
$8K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
73 |
33 |
$6K |
| D1110 |
Prophylaxis - adult |
74 |
74 |
$4K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
109 |
109 |
$3K |
| D0330 |
Panoramic radiographic image |
92 |
92 |
$3K |
| D0120 |
Periodic oral evaluation - established patient |
34 |
34 |
$909.15 |
| D1120 |
Prophylaxis - child |
21 |
21 |
$857.85 |
| D1206 |
Topical application of fluoride varnish |
51 |
51 |
$461.70 |
| D0274 |
Bitewings - four radiographic images |
76 |
76 |
$192.85 |
| D0220 |
Intraoral - periapical first radiographic image |
16 |
16 |
$39.90 |