| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
520 |
134 |
$35K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
446 |
446 |
$29K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
392 |
103 |
$21K |
| D0210 |
Intraoral - complete series of radiographic images |
405 |
405 |
$19K |
| D0350 |
|
606 |
163 |
$6K |
| D0330 |
Panoramic radiographic image |
64 |
63 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
70 |
70 |
$1K |
| D1120 |
Prophylaxis - child |
17 |
17 |
$787.50 |