| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
217 |
129 |
$20K |
| D0120 |
Periodic oral evaluation - established patient |
767 |
763 |
$20K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
110 |
76 |
$14K |
| D1110 |
Prophylaxis - adult |
243 |
243 |
$12K |
| D1206 |
Topical application of fluoride varnish |
180 |
180 |
$4K |
| D1120 |
Prophylaxis - child |
93 |
93 |
$4K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
93 |
93 |
$4K |
| D0330 |
Panoramic radiographic image |
38 |
38 |
$3K |
| D0274 |
Bitewings - four radiographic images |
13 |
13 |
$455.60 |