| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
756 |
212 |
$47K |
| D1110 |
Prophylaxis - adult |
756 |
737 |
$31K |
| D0120 |
Periodic oral evaluation - established patient |
1,425 |
1,406 |
$28K |
| D1206 |
Topical application of fluoride varnish |
1,712 |
1,682 |
$27K |
| D1120 |
Prophylaxis - child |
949 |
941 |
$27K |
| D0274 |
Bitewings - four radiographic images |
305 |
304 |
$10K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
80 |
39 |
$7K |
| D0330 |
Panoramic radiographic image |
64 |
64 |
$3K |
| D0272 |
Bitewings - two radiographic images |
141 |
141 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
16 |
16 |
$365.20 |