| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
132 |
69 |
$16K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
67 |
44 |
$6K |
| D1120 |
Prophylaxis - child |
108 |
105 |
$4K |
| D1208 |
Topical application of fluoride, excluding varnish |
114 |
111 |
$3K |
| D0120 |
Periodic oral evaluation - established patient |
97 |
94 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
31 |
31 |
$1K |
| D1110 |
Prophylaxis - adult |
26 |
26 |
$1K |
| D0274 |
Bitewings - four radiographic images |
26 |
25 |
$879.00 |
| D0272 |
Bitewings - two radiographic images |
12 |
12 |
$275.00 |