| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
280 |
152 |
$29K |
| D0120 |
Periodic oral evaluation - established patient |
543 |
543 |
$17K |
| D1110 |
Prophylaxis - adult |
274 |
274 |
$16K |
| D1206 |
Topical application of fluoride varnish |
453 |
453 |
$12K |
| D1120 |
Prophylaxis - child |
262 |
262 |
$11K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
65 |
43 |
$7K |
| D0274 |
Bitewings - four radiographic images |
120 |
120 |
$5K |
| D0272 |
Bitewings - two radiographic images |
143 |
143 |
$5K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
84 |
84 |
$4K |
| D0210 |
Intraoral - complete series of radiographic images |
29 |
29 |
$3K |