| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
453 |
229 |
$49K |
| D1120 |
Prophylaxis - child |
1,072 |
1,010 |
$32K |
| D0120 |
Periodic oral evaluation - established patient |
889 |
842 |
$24K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,145 |
1,077 |
$19K |
| D0140 |
Limited oral evaluation - problem focused |
281 |
258 |
$11K |
| D0330 |
Panoramic radiographic image |
115 |
110 |
$6K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
36 |
26 |
$3K |
| D0274 |
Bitewings - four radiographic images |
89 |
89 |
$3K |
| D0272 |
Bitewings - two radiographic images |
12 |
12 |
$240.31 |
| D0220 |
Intraoral - periapical first radiographic image |
21 |
18 |
$194.58 |
| D1999 |
|
29 |
24 |
$0.00 |