| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
967 |
532 |
$108K |
| D1120 |
Prophylaxis - child |
1,818 |
1,818 |
$66K |
| D0120 |
Periodic oral evaluation - established patient |
2,284 |
2,284 |
$57K |
| D1206 |
Topical application of fluoride varnish |
1,249 |
1,248 |
$27K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
265 |
141 |
$23K |
| D1110 |
Prophylaxis - adult |
334 |
334 |
$15K |
| D1208 |
Topical application of fluoride, excluding varnish |
405 |
405 |
$8K |
| D0272 |
Bitewings - two radiographic images |
262 |
262 |
$6K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
34 |
24 |
$5K |
| D0274 |
Bitewings - four radiographic images |
116 |
116 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
14 |
14 |
$473.00 |