| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
252 |
161 |
$21K |
| D1120 |
Prophylaxis - child |
252 |
252 |
$14K |
| D1206 |
Topical application of fluoride varnish |
351 |
351 |
$12K |
| D0120 |
Periodic oral evaluation - established patient |
401 |
398 |
$10K |
| D1110 |
Prophylaxis - adult |
158 |
155 |
$9K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
86 |
64 |
$6K |
| D0274 |
Bitewings - four radiographic images |
314 |
313 |
$6K |
| D0220 |
Intraoral - periapical first radiographic image |
370 |
369 |
$4K |
| D0230 |
Intraoral - periapical each additional radiographic image |
359 |
356 |
$3K |