| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
489 |
302 |
$57K |
| D1120 |
Prophylaxis - child |
705 |
705 |
$26K |
| D0120 |
Periodic oral evaluation - established patient |
902 |
901 |
$23K |
| D1208 |
Topical application of fluoride, excluding varnish |
760 |
760 |
$17K |
| D1110 |
Prophylaxis - adult |
298 |
297 |
$14K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
81 |
52 |
$7K |
| D0274 |
Bitewings - four radiographic images |
89 |
88 |
$3K |
| D0272 |
Bitewings - two radiographic images |
76 |
76 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
69 |
69 |
$1K |
| D0210 |
Intraoral - complete series of radiographic images |
13 |
13 |
$737.00 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
13 |
13 |
$516.00 |