| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
41 |
22 |
$3K |
| D0120 |
Periodic oral evaluation - established patient |
132 |
132 |
$3K |
| D0330 |
Panoramic radiographic image |
72 |
72 |
$3K |
| D1120 |
Prophylaxis - child |
62 |
62 |
$2K |
| D1206 |
Topical application of fluoride varnish |
121 |
121 |
$2K |
| D1110 |
Prophylaxis - adult |
54 |
54 |
$2K |
| D9110 |
|
51 |
51 |
$2K |
| D0274 |
Bitewings - four radiographic images |
24 |
24 |
$626.40 |
| D0230 |
Intraoral - periapical each additional radiographic image |
20 |
20 |
$331.00 |
| D0220 |
Intraoral - periapical first radiographic image |
31 |
31 |
$237.40 |