| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
119 |
59 |
$15K |
| D1120 |
Prophylaxis - child |
260 |
257 |
$9K |
| D0120 |
Periodic oral evaluation - established patient |
328 |
324 |
$8K |
| D1206 |
Topical application of fluoride varnish |
277 |
274 |
$6K |
| D0220 |
Intraoral - periapical first radiographic image |
179 |
176 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
17 |
12 |
$2K |
| D0274 |
Bitewings - four radiographic images |
25 |
25 |
$864.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
96 |
83 |
$828.00 |
| D1110 |
Prophylaxis - adult |
13 |
13 |
$702.00 |