| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
598 |
334 |
$70K |
| D1120 |
Prophylaxis - child |
1,061 |
1,061 |
$39K |
| D0120 |
Periodic oral evaluation - established patient |
1,230 |
1,230 |
$32K |
| D1206 |
Topical application of fluoride varnish |
924 |
924 |
$21K |
| D0272 |
Bitewings - two radiographic images |
326 |
325 |
$7K |
| D1110 |
Prophylaxis - adult |
106 |
106 |
$5K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
41 |
26 |
$4K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
49 |
49 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
68 |
68 |
$2K |