| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,127 |
645 |
$48K |
| D1110 |
Prophylaxis - adult |
1,185 |
1,112 |
$28K |
| D0120 |
Periodic oral evaluation - established patient |
1,602 |
1,513 |
$19K |
| D0274 |
Bitewings - four radiographic images |
716 |
676 |
$10K |
| D1120 |
Prophylaxis - child |
489 |
463 |
$9K |
| D1206 |
Topical application of fluoride varnish |
697 |
661 |
$8K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
76 |
63 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
472 |
425 |
$3K |
| D2331 |
|
38 |
29 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
49 |
46 |
$837.89 |
| D0272 |
Bitewings - two radiographic images |
60 |
58 |
$705.16 |
| D2951 |
|
18 |
14 |
$220.09 |