| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
54 |
31 |
$6K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
23 |
15 |
$3K |
| D1110 |
Prophylaxis - adult |
61 |
59 |
$2K |
| D0120 |
Periodic oral evaluation - established patient |
67 |
64 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
37 |
36 |
$2K |
| D0274 |
Bitewings - four radiographic images |
55 |
52 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
70 |
66 |
$974.80 |
| D1206 |
Topical application of fluoride varnish |
60 |
57 |
$771.88 |
| D0230 |
Intraoral - periapical each additional radiographic image |
64 |
58 |
$701.25 |
| D0330 |
Panoramic radiographic image |
13 |
12 |
$557.55 |