| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
45 |
27 |
$5K |
| D1120 |
Prophylaxis - child |
81 |
81 |
$3K |
| D0120 |
Periodic oral evaluation - established patient |
95 |
94 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
96 |
96 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
21 |
13 |
$2K |
| D0274 |
Bitewings - four radiographic images |
56 |
56 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
13 |
13 |
$559.00 |