| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
309 |
138 |
$30K |
| D1110 |
Prophylaxis - adult |
562 |
562 |
$30K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
272 |
146 |
$21K |
| D0120 |
Periodic oral evaluation - established patient |
513 |
512 |
$13K |
| D0274 |
Bitewings - four radiographic images |
354 |
354 |
$9K |
| D0220 |
Intraoral - periapical first radiographic image |
587 |
569 |
$9K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
131 |
74 |
$7K |
| D2394 |
|
41 |
24 |
$5K |
| D0210 |
Intraoral - complete series of radiographic images |
73 |
73 |
$4K |
| D9110 |
|
43 |
42 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
26 |
26 |
$654.65 |
| D1208 |
Topical application of fluoride, excluding varnish |
15 |
15 |
$185.25 |