| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
83 |
28 |
$4K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
36 |
17 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
55 |
23 |
$2K |
| D0120 |
Periodic oral evaluation - established patient |
63 |
63 |
$1K |
| D1110 |
Prophylaxis - adult |
28 |
28 |
$1K |
| D0274 |
Bitewings - four radiographic images |
49 |
49 |
$927.52 |
| D0220 |
Intraoral - periapical first radiographic image |
61 |
61 |
$655.80 |
| D1120 |
Prophylaxis - child |
14 |
14 |
$383.27 |
| D1208 |
Topical application of fluoride, excluding varnish |
15 |
15 |
$130.34 |