| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
864 |
481 |
$58K |
| D1110 |
Prophylaxis - adult |
1,641 |
1,529 |
$55K |
| D0120 |
Periodic oral evaluation - established patient |
2,452 |
2,233 |
$40K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
482 |
296 |
$25K |
| D1206 |
Topical application of fluoride varnish |
1,439 |
1,295 |
$21K |
| D1120 |
Prophylaxis - child |
765 |
647 |
$18K |
| D0274 |
Bitewings - four radiographic images |
829 |
760 |
$18K |
| D1208 |
Topical application of fluoride, excluding varnish |
600 |
544 |
$9K |
| D0230 |
Intraoral - periapical each additional radiographic image |
237 |
105 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
177 |
131 |
$2K |
| D0330 |
Panoramic radiographic image |
12 |
12 |
$502.45 |
| D0272 |
Bitewings - two radiographic images |
35 |
26 |
$461.92 |