| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
493 |
276 |
$61K |
| D0120 |
Periodic oral evaluation - established patient |
1,172 |
1,170 |
$32K |
| D1110 |
Prophylaxis - adult |
608 |
607 |
$31K |
| D1120 |
Prophylaxis - child |
681 |
681 |
$28K |
| D1206 |
Topical application of fluoride varnish |
798 |
798 |
$20K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
93 |
71 |
$9K |
| D0272 |
Bitewings - two radiographic images |
345 |
344 |
$8K |
| D1208 |
Topical application of fluoride, excluding varnish |
80 |
80 |
$2K |
| D1351 |
Sealant - per tooth |
31 |
15 |
$930.00 |