| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,236 |
431 |
$86K |
| D1110 |
Prophylaxis - adult |
1,399 |
1,399 |
$56K |
| D0120 |
Periodic oral evaluation - established patient |
1,861 |
1,861 |
$38K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
443 |
232 |
$37K |
| D0274 |
Bitewings - four radiographic images |
1,417 |
1,417 |
$29K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
501 |
221 |
$24K |
| D0220 |
Intraoral - periapical first radiographic image |
1,391 |
1,388 |
$19K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,079 |
1,079 |
$15K |
| D1120 |
Prophylaxis - child |
144 |
144 |
$5K |
| D1208 |
Topical application of fluoride, excluding varnish |
338 |
338 |
$4K |
| D4341 |
|
26 |
12 |
$1K |