| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
905 |
562 |
$106K |
| D1120 |
Prophylaxis - child |
935 |
932 |
$34K |
| D0120 |
Periodic oral evaluation - established patient |
1,016 |
1,016 |
$26K |
| D1206 |
Topical application of fluoride varnish |
1,043 |
1,041 |
$24K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
77 |
63 |
$7K |
| D0220 |
Intraoral - periapical first radiographic image |
238 |
234 |
$4K |
| D1110 |
Prophylaxis - adult |
80 |
80 |
$4K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
15 |
12 |
$2K |
| D0272 |
Bitewings - two radiographic images |
63 |
63 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
28 |
28 |
$243.00 |