| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
389 |
200 |
$46K |
| D1110 |
Prophylaxis - adult |
621 |
619 |
$30K |
| D0120 |
Periodic oral evaluation - established patient |
779 |
777 |
$19K |
| D1120 |
Prophylaxis - child |
485 |
485 |
$17K |
| D1206 |
Topical application of fluoride varnish |
508 |
508 |
$11K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
141 |
141 |
$6K |
| D0274 |
Bitewings - four radiographic images |
175 |
174 |
$6K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
19 |
13 |
$2K |