| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
128 |
50 |
$16K |
| D1110 |
Prophylaxis - adult |
215 |
210 |
$9K |
| D1120 |
Prophylaxis - child |
164 |
164 |
$7K |
| D0120 |
Periodic oral evaluation - established patient |
260 |
256 |
$7K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
56 |
27 |
$5K |
| D1208 |
Topical application of fluoride, excluding varnish |
162 |
162 |
$4K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
19 |
12 |
$3K |
| D0274 |
Bitewings - four radiographic images |
67 |
65 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
62 |
59 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
47 |
47 |
$2K |
| D0272 |
Bitewings - two radiographic images |
46 |
46 |
$1K |