| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
215 |
124 |
$24K |
| D1110 |
Prophylaxis - adult |
281 |
281 |
$16K |
| D0120 |
Periodic oral evaluation - established patient |
531 |
531 |
$13K |
| D1208 |
Topical application of fluoride, excluding varnish |
443 |
443 |
$11K |
| D1120 |
Prophylaxis - child |
249 |
249 |
$10K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
97 |
63 |
$9K |
| D0274 |
Bitewings - four radiographic images |
202 |
202 |
$7K |
| D1351 |
Sealant - per tooth |
46 |
17 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
29 |
28 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
37 |
37 |
$1K |
| D0272 |
Bitewings - two radiographic images |
14 |
14 |
$366.80 |