| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
3,007 |
1,189 |
$394K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
3,722 |
1,315 |
$304K |
| D0120 |
Periodic oral evaluation - established patient |
1,440 |
1,417 |
$38K |
| D1110 |
Prophylaxis - adult |
895 |
876 |
$34K |
| D1208 |
Topical application of fluoride, excluding varnish |
922 |
915 |
$16K |
| D1120 |
Prophylaxis - child |
226 |
220 |
$6K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
31 |
25 |
$3K |
| D0272 |
Bitewings - two radiographic images |
167 |
166 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
52 |
51 |
$789.96 |