| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
47 |
27 |
$5K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
87 |
87 |
$4K |
| D1120 |
Prophylaxis - child |
87 |
87 |
$2K |
| D1351 |
Sealant - per tooth |
86 |
15 |
$2K |
| D0330 |
Panoramic radiographic image |
33 |
32 |
$2K |
| D1206 |
Topical application of fluoride varnish |
47 |
47 |
$1K |
| D0274 |
Bitewings - four radiographic images |
35 |
35 |
$771.12 |
| D0272 |
Bitewings - two radiographic images |
33 |
33 |
$527.80 |
| D1208 |
Topical application of fluoride, excluding varnish |
25 |
25 |
$405.88 |