| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
100 |
39 |
$10K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
77 |
35 |
$10K |
| D2394 |
|
53 |
30 |
$8K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
67 |
67 |
$3K |
| D1110 |
Prophylaxis - adult |
33 |
33 |
$2K |
| D0274 |
Bitewings - four radiographic images |
42 |
42 |
$2K |
| D1206 |
Topical application of fluoride varnish |
28 |
28 |
$825.44 |
| D0220 |
Intraoral - periapical first radiographic image |
56 |
56 |
$550.48 |
| D0230 |
Intraoral - periapical each additional radiographic image |
52 |
52 |
$511.16 |