| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
220 |
76 |
$22K |
| D0120 |
Periodic oral evaluation - established patient |
303 |
298 |
$8K |
| D1208 |
Topical application of fluoride, excluding varnish |
414 |
409 |
$6K |
| D0274 |
Bitewings - four radiographic images |
192 |
187 |
$5K |
| D1120 |
Prophylaxis - child |
123 |
119 |
$4K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
50 |
16 |
$4K |
| D1110 |
Prophylaxis - adult |
52 |
51 |
$3K |
| D1351 |
Sealant - per tooth |
53 |
13 |
$1K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
17 |
17 |
$529.80 |
| D0603 |
|
223 |
217 |
$0.01 |
| D0601 |
|
15 |
15 |
$0.00 |
| D0602 |
|
21 |
19 |
$0.00 |