| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
45 |
26 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
75 |
74 |
$1K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
25 |
14 |
$1K |
| D1120 |
Prophylaxis - child |
35 |
34 |
$1K |
| D0120 |
Periodic oral evaluation - established patient |
38 |
37 |
$756.10 |
| D1110 |
Prophylaxis - adult |
20 |
20 |
$712.35 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
21 |
21 |
$420.00 |
| D0274 |
Bitewings - four radiographic images |
12 |
12 |
$336.00 |