| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
464 |
245 |
$47K |
| D1120 |
Prophylaxis - child |
488 |
472 |
$13K |
| D0120 |
Periodic oral evaluation - established patient |
609 |
585 |
$10K |
| D0274 |
Bitewings - four radiographic images |
340 |
321 |
$10K |
| D1110 |
Prophylaxis - adult |
210 |
195 |
$9K |
| D0272 |
Bitewings - two radiographic images |
296 |
285 |
$5K |
| D1206 |
Topical application of fluoride varnish |
123 |
118 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
16 |
14 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
86 |
81 |
$881.05 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
13 |
12 |
$322.68 |