| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
242 |
70 |
$23K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
238 |
65 |
$17K |
| D0120 |
Periodic oral evaluation - established patient |
328 |
327 |
$9K |
| D1120 |
Prophylaxis - child |
198 |
198 |
$7K |
| D1110 |
Prophylaxis - adult |
103 |
102 |
$5K |
| D1206 |
Topical application of fluoride varnish |
326 |
326 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
339 |
335 |
$4K |
| D0230 |
Intraoral - periapical each additional radiographic image |
344 |
325 |
$4K |
| D0272 |
Bitewings - two radiographic images |
156 |
156 |
$4K |
| D0274 |
Bitewings - four radiographic images |
102 |
102 |
$3K |
| D0350 |
|
198 |
198 |
$3K |
| D0601 |
|
415 |
415 |
$0.00 |