| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
323 |
204 |
$36K |
| D1110 |
Prophylaxis - adult |
406 |
405 |
$20K |
| D1120 |
Prophylaxis - child |
479 |
479 |
$19K |
| D0120 |
Periodic oral evaluation - established patient |
669 |
668 |
$17K |
| D1206 |
Topical application of fluoride varnish |
532 |
532 |
$13K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
176 |
176 |
$7K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
29 |
20 |
$3K |
| D0274 |
Bitewings - four radiographic images |
69 |
69 |
$2K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
17 |
12 |
$2K |
| D0330 |
Panoramic radiographic image |
14 |
14 |
$921.12 |
| D0272 |
Bitewings - two radiographic images |
32 |
32 |
$765.00 |
| D0240 |
|
30 |
15 |
$630.00 |