| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
433 |
220 |
$49K |
| D1120 |
Prophylaxis - child |
583 |
583 |
$21K |
| D1206 |
Topical application of fluoride varnish |
820 |
820 |
$19K |
| D0120 |
Periodic oral evaluation - established patient |
670 |
670 |
$17K |
| D1110 |
Prophylaxis - adult |
214 |
214 |
$10K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
66 |
41 |
$8K |
| D0330 |
Panoramic radiographic image |
146 |
146 |
$8K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
75 |
75 |
$3K |
| D0274 |
Bitewings - four radiographic images |
79 |
79 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
19 |
13 |
$2K |