| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
937 |
760 |
$77K |
| D1110 |
Prophylaxis - adult |
1,984 |
1,983 |
$66K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,194 |
893 |
$52K |
| D0120 |
Periodic oral evaluation - established patient |
2,413 |
2,412 |
$48K |
| D0274 |
Bitewings - four radiographic images |
2,100 |
2,100 |
$40K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,698 |
2,692 |
$20K |
| D0220 |
Intraoral - periapical first radiographic image |
2,032 |
2,022 |
$19K |
| D1208 |
Topical application of fluoride, excluding varnish |
242 |
242 |
$2K |
| D2331 |
|
40 |
30 |
$2K |
| D2330 |
|
26 |
26 |
$1K |
| D2332 |
|
12 |
12 |
$954.05 |
| D1120 |
Prophylaxis - child |
24 |
24 |
$662.16 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
13 |
13 |
$254.60 |