| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
77 |
39 |
$4K |
| D0330 |
Panoramic radiographic image |
56 |
56 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
67 |
67 |
$2K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
16 |
12 |
$1K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
17 |
12 |
$943.69 |
| D1110 |
Prophylaxis - adult |
13 |
13 |
$455.61 |
| D0120 |
Periodic oral evaluation - established patient |
20 |
20 |
$324.53 |
| D0274 |
Bitewings - four radiographic images |
14 |
14 |
$246.00 |