| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
249 |
135 |
$31K |
| D1120 |
Prophylaxis - child |
221 |
221 |
$9K |
| D0120 |
Periodic oral evaluation - established patient |
235 |
235 |
$7K |
| D1206 |
Topical application of fluoride varnish |
251 |
251 |
$6K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
18 |
12 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
132 |
118 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
16 |
12 |
$1K |
| D1110 |
Prophylaxis - adult |
16 |
16 |
$864.00 |
| D0274 |
Bitewings - four radiographic images |
26 |
26 |
$840.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
82 |
53 |
$711.00 |
| D0272 |
Bitewings - two radiographic images |
14 |
14 |
$336.00 |