| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
117 |
55 |
$15K |
| D1120 |
Prophylaxis - child |
310 |
310 |
$12K |
| D1206 |
Topical application of fluoride varnish |
332 |
332 |
$8K |
| D0120 |
Periodic oral evaluation - established patient |
280 |
280 |
$7K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
164 |
164 |
$7K |
| D1110 |
Prophylaxis - adult |
81 |
81 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
207 |
206 |
$3K |
| D0210 |
Intraoral - complete series of radiographic images |
42 |
42 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
136 |
130 |
$1K |
| D0274 |
Bitewings - four radiographic images |
30 |
30 |
$1K |