| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
350 |
181 |
$31K |
| D1120 |
Prophylaxis - child |
903 |
896 |
$30K |
| D1206 |
Topical application of fluoride varnish |
1,302 |
1,286 |
$27K |
| D0120 |
Periodic oral evaluation - established patient |
1,250 |
1,232 |
$25K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
293 |
168 |
$22K |
| D1110 |
Prophylaxis - adult |
402 |
395 |
$19K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
114 |
111 |
$4K |
| D0210 |
Intraoral - complete series of radiographic images |
52 |
48 |
$3K |
| D0274 |
Bitewings - four radiographic images |
86 |
84 |
$2K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
20 |
14 |
$2K |
| D0272 |
Bitewings - two radiographic images |
14 |
14 |
$282.10 |
| D1208 |
Topical application of fluoride, excluding varnish |
12 |
12 |
$249.48 |
| D0220 |
Intraoral - periapical first radiographic image |
13 |
13 |
$145.34 |