| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
209 |
137 |
$23K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
92 |
60 |
$9K |
| D1110 |
Prophylaxis - adult |
70 |
70 |
$4K |
| D0120 |
Periodic oral evaluation - established patient |
48 |
48 |
$2K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
15 |
12 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
31 |
31 |
$1K |
| D1206 |
Topical application of fluoride varnish |
17 |
17 |
$544.00 |
| D0220 |
Intraoral - periapical first radiographic image |
33 |
33 |
$490.00 |
| D0603 |
|
12 |
12 |
$120.00 |