| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
808 |
314 |
$44K |
| D0120 |
Periodic oral evaluation - established patient |
1,124 |
1,102 |
$25K |
| D1110 |
Prophylaxis - adult |
659 |
643 |
$17K |
| D1120 |
Prophylaxis - child |
824 |
808 |
$16K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,415 |
1,383 |
$15K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
464 |
450 |
$15K |
| D0272 |
Bitewings - two radiographic images |
1,027 |
1,003 |
$14K |
| D1351 |
Sealant - per tooth |
468 |
95 |
$9K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
92 |
49 |
$6K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
43 |
25 |
$2K |