| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
43 |
15 |
$4K |
| D1110 |
Prophylaxis - adult |
74 |
67 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
45 |
42 |
$2K |
| D0330 |
Panoramic radiographic image |
28 |
26 |
$1K |
| D0274 |
Bitewings - four radiographic images |
54 |
52 |
$1K |
| D0120 |
Periodic oral evaluation - established patient |
48 |
42 |
$911.60 |
| D0140 |
Limited oral evaluation - problem focused |
13 |
13 |
$299.40 |
| D1206 |
Topical application of fluoride varnish |
12 |
12 |
$299.04 |