| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
48 |
24 |
$4K |
| D0120 |
Periodic oral evaluation - established patient |
89 |
89 |
$2K |
| D9630 |
|
91 |
91 |
$2K |
| D1110 |
Prophylaxis - adult |
33 |
33 |
$1K |
| D1206 |
Topical application of fluoride varnish |
75 |
75 |
$1K |
| D1120 |
Prophylaxis - child |
29 |
29 |
$972.08 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
32 |
30 |
$907.99 |
| D1208 |
Topical application of fluoride, excluding varnish |
41 |
41 |
$852.39 |
| D0274 |
Bitewings - four radiographic images |
42 |
42 |
$745.20 |
| D0230 |
Intraoral - periapical each additional radiographic image |
69 |
56 |
$357.76 |
| D0220 |
Intraoral - periapical first radiographic image |
68 |
67 |
$346.58 |
| D0330 |
Panoramic radiographic image |
12 |
12 |
$215.96 |