| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
463 |
307 |
$51K |
| D0120 |
Periodic oral evaluation - established patient |
1,279 |
1,241 |
$39K |
| D1120 |
Prophylaxis - child |
878 |
860 |
$37K |
| D1206 |
Topical application of fluoride varnish |
1,334 |
1,300 |
$35K |
| D0274 |
Bitewings - four radiographic images |
750 |
726 |
$29K |
| D1110 |
Prophylaxis - adult |
548 |
528 |
$28K |
| D0272 |
Bitewings - two radiographic images |
435 |
421 |
$13K |
| D1351 |
Sealant - per tooth |
321 |
124 |
$13K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
104 |
98 |
$5K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
20 |
13 |
$3K |