| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
17 |
14 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
19 |
15 |
$2K |
| D0120 |
Periodic oral evaluation - established patient |
57 |
57 |
$1K |
| D1120 |
Prophylaxis - child |
37 |
37 |
$1K |
| D1110 |
Prophylaxis - adult |
24 |
24 |
$1K |
| D1206 |
Topical application of fluoride varnish |
31 |
31 |
$775.00 |
| D0274 |
Bitewings - four radiographic images |
24 |
24 |
$747.73 |
| D0220 |
Intraoral - periapical first radiographic image |
53 |
53 |
$692.92 |
| D1208 |
Topical application of fluoride, excluding varnish |
15 |
15 |
$325.56 |
| D0230 |
Intraoral - periapical each additional radiographic image |
35 |
35 |
$277.58 |