| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
426 |
244 |
$33K |
| D1110 |
Prophylaxis - adult |
433 |
433 |
$24K |
| D0274 |
Bitewings - four radiographic images |
378 |
378 |
$12K |
| D0120 |
Periodic oral evaluation - established patient |
384 |
384 |
$10K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
102 |
73 |
$10K |
| D0330 |
Panoramic radiographic image |
170 |
170 |
$6K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
119 |
69 |
$6K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
188 |
188 |
$5K |
| D1120 |
Prophylaxis - child |
123 |
123 |
$5K |
| D1208 |
Topical application of fluoride, excluding varnish |
191 |
191 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
155 |
152 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
26 |
26 |
$347.20 |