| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
237 |
129 |
$23K |
| D1120 |
Prophylaxis - child |
131 |
130 |
$4K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
43 |
30 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
83 |
65 |
$3K |
| D1206 |
Topical application of fluoride varnish |
117 |
116 |
$3K |
| D0120 |
Periodic oral evaluation - established patient |
57 |
57 |
$2K |
| D0330 |
Panoramic radiographic image |
12 |
12 |
$683.36 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
13 |
13 |
$558.03 |
| D0220 |
Intraoral - periapical first radiographic image |
15 |
15 |
$139.26 |