| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
252 |
82 |
$31K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
171 |
67 |
$16K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
44 |
29 |
$7K |
| D1120 |
Prophylaxis - child |
82 |
82 |
$3K |
| D1208 |
Topical application of fluoride, excluding varnish |
105 |
105 |
$3K |
| D1110 |
Prophylaxis - adult |
44 |
44 |
$2K |
| D0120 |
Periodic oral evaluation - established patient |
78 |
78 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
47 |
47 |
$2K |
| D2332 |
|
17 |
13 |
$2K |
| D0274 |
Bitewings - four radiographic images |
34 |
34 |
$1K |