| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
117 |
46 |
$12K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
76 |
41 |
$11K |
| D1110 |
Prophylaxis - adult |
145 |
145 |
$6K |
| D0120 |
Periodic oral evaluation - established patient |
172 |
172 |
$4K |
| D0274 |
Bitewings - four radiographic images |
110 |
110 |
$3K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
17 |
12 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
51 |
51 |
$2K |
| D1120 |
Prophylaxis - child |
41 |
41 |
$1K |
| D1206 |
Topical application of fluoride varnish |
42 |
42 |
$703.45 |
| D0220 |
Intraoral - periapical first radiographic image |
51 |
51 |
$606.90 |