| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
122 |
51 |
$17K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
259 |
258 |
$14K |
| D0330 |
Panoramic radiographic image |
310 |
309 |
$14K |
| D1110 |
Prophylaxis - adult |
179 |
179 |
$12K |
| D0140 |
Limited oral evaluation - problem focused |
210 |
207 |
$10K |
| D3330 |
Endodontic therapy, molar tooth (excluding final restoration) |
12 |
12 |
$9K |
| D0220 |
Intraoral - periapical first radiographic image |
740 |
654 |
$9K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
81 |
40 |
$9K |
| D0274 |
Bitewings - four radiographic images |
288 |
287 |
$7K |
| D0120 |
Periodic oral evaluation - established patient |
90 |
90 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
325 |
324 |
$2K |
| D1206 |
Topical application of fluoride varnish |
24 |
14 |
$348.88 |