| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
453 |
284 |
$55K |
| D0120 |
Periodic oral evaluation - established patient |
1,450 |
1,448 |
$38K |
| D1120 |
Prophylaxis - child |
640 |
640 |
$25K |
| D1110 |
Prophylaxis - adult |
370 |
369 |
$18K |
| D1206 |
Topical application of fluoride varnish |
721 |
721 |
$18K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
208 |
111 |
$18K |
| D0220 |
Intraoral - periapical first radiographic image |
1,082 |
1,035 |
$17K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
52 |
30 |
$8K |
| D0230 |
Intraoral - periapical each additional radiographic image |
792 |
461 |
$7K |
| D0274 |
Bitewings - four radiographic images |
181 |
181 |
$6K |
| D1208 |
Topical application of fluoride, excluding varnish |
86 |
86 |
$2K |
| D1999 |
|
55 |
46 |
$0.00 |