| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
550 |
186 |
$70K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
245 |
135 |
$22K |
| D1120 |
Prophylaxis - child |
105 |
105 |
$4K |
| D1206 |
Topical application of fluoride varnish |
131 |
131 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
39 |
39 |
$2K |
| D0120 |
Periodic oral evaluation - established patient |
43 |
43 |
$1K |
| D0330 |
Panoramic radiographic image |
12 |
12 |
$864.00 |