| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
182 |
65 |
$21K |
| D1120 |
Prophylaxis - child |
551 |
551 |
$18K |
| D1208 |
Topical application of fluoride, excluding varnish |
817 |
817 |
$17K |
| D0120 |
Periodic oral evaluation - established patient |
702 |
702 |
$14K |
| D2394 |
|
43 |
13 |
$5K |
| D1110 |
Prophylaxis - adult |
108 |
102 |
$5K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
19 |
13 |
$2K |
| D0274 |
Bitewings - four radiographic images |
57 |
54 |
$1K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
35 |
35 |
$1K |
| D0272 |
Bitewings - two radiographic images |
39 |
39 |
$785.85 |
| D0140 |
Limited oral evaluation - problem focused |
26 |
24 |
$595.92 |