| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
460 |
191 |
$42K |
| D0274 |
Bitewings - four radiographic images |
511 |
511 |
$21K |
| D0120 |
Periodic oral evaluation - established patient |
657 |
656 |
$18K |
| D1110 |
Prophylaxis - adult |
299 |
299 |
$17K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
224 |
121 |
$16K |
| D1120 |
Prophylaxis - child |
357 |
357 |
$16K |
| D1206 |
Topical application of fluoride varnish |
565 |
565 |
$12K |
| D0220 |
Intraoral - periapical first radiographic image |
378 |
376 |
$6K |
| D0230 |
Intraoral - periapical each additional radiographic image |
298 |
278 |
$4K |