| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
101 |
67 |
$13K |
| D1110 |
Prophylaxis - adult |
136 |
136 |
$10K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
109 |
109 |
$6K |
| D0330 |
Panoramic radiographic image |
66 |
66 |
$6K |
| D0274 |
Bitewings - four radiographic images |
106 |
106 |
$5K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
49 |
30 |
$5K |
| D1206 |
Topical application of fluoride varnish |
90 |
90 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
42 |
39 |
$2K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
14 |
14 |
$2K |
| D0120 |
Periodic oral evaluation - established patient |
49 |
49 |
$2K |
| D1330 |
|
40 |
40 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
33 |
33 |
$734.99 |