| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,306 |
705 |
$86K |
| D1110 |
Prophylaxis - adult |
1,419 |
1,416 |
$41K |
| D0330 |
Panoramic radiographic image |
1,288 |
1,288 |
$25K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,095 |
1,093 |
$17K |
| D0120 |
Periodic oral evaluation - established patient |
762 |
762 |
$14K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
317 |
201 |
$11K |
| D2332 |
|
82 |
15 |
$2K |
| D1206 |
Topical application of fluoride varnish |
31 |
31 |
$709.33 |
| D0272 |
Bitewings - two radiographic images |
38 |
38 |
$411.77 |
| D1120 |
Prophylaxis - child |
12 |
12 |
$321.10 |
| D1208 |
Topical application of fluoride, excluding varnish |
27 |
27 |
$240.83 |