| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
851 |
192 |
$45K |
| D1110 |
Prophylaxis - adult |
639 |
631 |
$21K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
420 |
129 |
$18K |
| D0274 |
Bitewings - four radiographic images |
677 |
666 |
$16K |
| D0120 |
Periodic oral evaluation - established patient |
392 |
385 |
$7K |
| D0330 |
Panoramic radiographic image |
119 |
119 |
$4K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
150 |
150 |
$3K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
21 |
12 |
$1K |
| D9110 |
|
13 |
13 |
$376.80 |
| D1208 |
Topical application of fluoride, excluding varnish |
13 |
13 |
$219.51 |
| D1206 |
Topical application of fluoride varnish |
75 |
74 |
$86.04 |