| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
63 |
25 |
$5K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
172 |
137 |
$4K |
| D1208 |
Topical application of fluoride, excluding varnish |
182 |
182 |
$3K |
| D0120 |
Periodic oral evaluation - established patient |
145 |
143 |
$3K |
| D1120 |
Prophylaxis - child |
86 |
86 |
$2K |
| D1206 |
Topical application of fluoride varnish |
65 |
62 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
90 |
70 |
$760.24 |
| D0330 |
Panoramic radiographic image |
17 |
13 |
$701.87 |
| D1110 |
Prophylaxis - adult |
12 |
12 |
$566.28 |
| D0210 |
Intraoral - complete series of radiographic images |
26 |
16 |
$537.12 |
| D0230 |
Intraoral - periapical each additional radiographic image |
51 |
14 |
$380.12 |