| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
125 |
74 |
$8K |
| D1120 |
Prophylaxis - child |
37 |
37 |
$2K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
26 |
16 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
47 |
47 |
$2K |
| D1110 |
Prophylaxis - adult |
25 |
25 |
$1K |
| D1208 |
Topical application of fluoride, excluding varnish |
47 |
47 |
$858.75 |
| D0330 |
Panoramic radiographic image |
12 |
12 |
$702.05 |
| D0272 |
Bitewings - two radiographic images |
12 |
12 |
$235.43 |