| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,216 |
439 |
$182K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
696 |
397 |
$137K |
| D1351 |
Sealant - per tooth |
1,370 |
415 |
$71K |
| D1120 |
Prophylaxis - child |
917 |
907 |
$61K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
693 |
682 |
$57K |
| D0210 |
Intraoral - complete series of radiographic images |
394 |
383 |
$48K |
| D1206 |
Topical application of fluoride varnish |
1,021 |
1,011 |
$42K |
| D0120 |
Periodic oral evaluation - established patient |
369 |
369 |
$17K |
| D0272 |
Bitewings - two radiographic images |
181 |
181 |
$8K |
| D1110 |
Prophylaxis - adult |
64 |
64 |
$5K |
| D0274 |
Bitewings - four radiographic images |
87 |
87 |
$4K |