| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
53 |
36 |
$4K |
| D1110 |
Prophylaxis - adult |
71 |
71 |
$3K |
| D0120 |
Periodic oral evaluation - established patient |
131 |
131 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
39 |
31 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
217 |
217 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
181 |
181 |
$1K |
| D0274 |
Bitewings - four radiographic images |
61 |
61 |
$1K |
| D1120 |
Prophylaxis - child |
32 |
32 |
$969.17 |
| D1208 |
Topical application of fluoride, excluding varnish |
75 |
75 |
$836.40 |