| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
488 |
245 |
$42K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
100 |
56 |
$11K |
| D1120 |
Prophylaxis - child |
281 |
281 |
$8K |
| D1206 |
Topical application of fluoride varnish |
532 |
530 |
$8K |
| D0120 |
Periodic oral evaluation - established patient |
377 |
377 |
$7K |
| D0274 |
Bitewings - four radiographic images |
172 |
172 |
$5K |
| D1110 |
Prophylaxis - adult |
70 |
70 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
27 |
14 |
$1K |
| D0330 |
Panoramic radiographic image |
25 |
25 |
$1K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
24 |
24 |
$676.80 |
| D0272 |
Bitewings - two radiographic images |
12 |
12 |
$203.04 |