| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
119 |
40 |
$11K |
| D0120 |
Periodic oral evaluation - established patient |
299 |
299 |
$8K |
| D1120 |
Prophylaxis - child |
158 |
158 |
$6K |
| D1208 |
Topical application of fluoride, excluding varnish |
228 |
227 |
$5K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
25 |
14 |
$3K |
| D1110 |
Prophylaxis - adult |
27 |
27 |
$1K |
| D0330 |
Panoramic radiographic image |
13 |
13 |
$657.82 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
16 |
16 |
$602.00 |