| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
84 |
29 |
$9K |
| D1110 |
Prophylaxis - adult |
105 |
94 |
$5K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
58 |
27 |
$5K |
| D0272 |
Bitewings - two radiographic images |
170 |
151 |
$4K |
| D0120 |
Periodic oral evaluation - established patient |
82 |
70 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
78 |
71 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
15 |
12 |
$617.28 |