| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
32 |
19 |
$3K |
| D1110 |
Prophylaxis - adult |
34 |
34 |
$2K |
| D0274 |
Bitewings - four radiographic images |
41 |
41 |
$1K |
| D0120 |
Periodic oral evaluation - established patient |
35 |
35 |
$805.00 |
| D0330 |
Panoramic radiographic image |
13 |
13 |
$651.17 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
15 |
15 |
$607.50 |
| D1208 |
Topical application of fluoride, excluding varnish |
35 |
35 |
$567.00 |
| D0220 |
Intraoral - periapical first radiographic image |
12 |
12 |
$153.96 |