| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
470 |
237 |
$60K |
| D1120 |
Prophylaxis - child |
694 |
634 |
$26K |
| D1110 |
Prophylaxis - adult |
299 |
274 |
$15K |
| D1206 |
Topical application of fluoride varnish |
671 |
634 |
$14K |
| D0120 |
Periodic oral evaluation - established patient |
546 |
503 |
$13K |
| D1208 |
Topical application of fluoride, excluding varnish |
555 |
482 |
$9K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
30 |
13 |
$1K |
| D0274 |
Bitewings - four radiographic images |
40 |
38 |
$1K |