| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
936 |
599 |
$77K |
| D1110 |
Prophylaxis - adult |
725 |
725 |
$41K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
370 |
259 |
$36K |
| D0120 |
Periodic oral evaluation - established patient |
1,110 |
1,110 |
$32K |
| D0274 |
Bitewings - four radiographic images |
695 |
695 |
$17K |
| D0220 |
Intraoral - periapical first radiographic image |
627 |
624 |
$8K |
| D1208 |
Topical application of fluoride, excluding varnish |
249 |
249 |
$3K |
| D1120 |
Prophylaxis - child |
77 |
77 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
32 |
28 |
$2K |
| D0272 |
Bitewings - two radiographic images |
26 |
26 |
$442.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
77 |
77 |
$393.93 |