| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
449 |
199 |
$60K |
| D1110 |
Prophylaxis - adult |
696 |
689 |
$45K |
| D0120 |
Periodic oral evaluation - established patient |
610 |
603 |
$19K |
| D1206 |
Topical application of fluoride varnish |
658 |
658 |
$17K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
77 |
42 |
$13K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
101 |
48 |
$11K |
| D0274 |
Bitewings - four radiographic images |
232 |
230 |
$6K |
| D2950 |
|
25 |
12 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
25 |
25 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
108 |
102 |
$1K |
| D1120 |
Prophylaxis - child |
25 |
25 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
28 |
28 |
$347.68 |