| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
658 |
172 |
$82K |
| D1110 |
Prophylaxis - adult |
764 |
762 |
$45K |
| D0120 |
Periodic oral evaluation - established patient |
1,178 |
1,172 |
$36K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
219 |
78 |
$30K |
| D0210 |
Intraoral - complete series of radiographic images |
485 |
484 |
$29K |
| D0274 |
Bitewings - four radiographic images |
620 |
620 |
$20K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
313 |
313 |
$13K |
| D1120 |
Prophylaxis - child |
99 |
99 |
$4K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
75 |
25 |
$4K |
| D1208 |
Topical application of fluoride, excluding varnish |
115 |
115 |
$2K |