| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,161 |
541 |
$122K |
| D1110 |
Prophylaxis - adult |
2,036 |
1,980 |
$75K |
| D0120 |
Periodic oral evaluation - established patient |
2,526 |
2,454 |
$64K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
440 |
203 |
$36K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
239 |
139 |
$29K |
| D1206 |
Topical application of fluoride varnish |
1,046 |
1,011 |
$17K |
| D2332 |
|
174 |
90 |
$16K |
| D0274 |
Bitewings - four radiographic images |
364 |
349 |
$11K |
| D2331 |
|
117 |
68 |
$9K |
| D1120 |
Prophylaxis - child |
171 |
168 |
$5K |
| D9110 |
|
12 |
12 |
$530.24 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
14 |
12 |
$462.50 |
| D0272 |
Bitewings - two radiographic images |
12 |
12 |
$211.08 |