| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
422 |
280 |
$57K |
| D1110 |
Prophylaxis - adult |
481 |
481 |
$27K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
255 |
168 |
$27K |
| D0330 |
Panoramic radiographic image |
302 |
302 |
$22K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
103 |
85 |
$16K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
338 |
338 |
$16K |
| D0120 |
Periodic oral evaluation - established patient |
472 |
472 |
$14K |
| D0274 |
Bitewings - four radiographic images |
385 |
385 |
$11K |
| D1120 |
Prophylaxis - child |
109 |
109 |
$5K |
| D0140 |
Limited oral evaluation - problem focused |
30 |
30 |
$1K |
| D1206 |
Topical application of fluoride varnish |
24 |
24 |
$705.10 |
| D1208 |
Topical application of fluoride, excluding varnish |
13 |
13 |
$335.00 |