| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
266 |
166 |
$28K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
189 |
116 |
$14K |
| D0274 |
Bitewings - four radiographic images |
294 |
287 |
$8K |
| D1110 |
Prophylaxis - adult |
302 |
297 |
$8K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
233 |
230 |
$5K |
| D1206 |
Topical application of fluoride varnish |
253 |
249 |
$3K |
| D1120 |
Prophylaxis - child |
121 |
120 |
$3K |
| D0120 |
Periodic oral evaluation - established patient |
94 |
94 |
$2K |
| D0272 |
Bitewings - two radiographic images |
17 |
17 |
$307.87 |
| D0220 |
Intraoral - periapical first radiographic image |
13 |
12 |
$129.49 |