| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
173 |
86 |
$15K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
193 |
95 |
$14K |
| D0120 |
Periodic oral evaluation - established patient |
395 |
394 |
$11K |
| D1120 |
Prophylaxis - child |
218 |
217 |
$8K |
| D0274 |
Bitewings - four radiographic images |
260 |
259 |
$7K |
| D1110 |
Prophylaxis - adult |
136 |
135 |
$7K |
| D1208 |
Topical application of fluoride, excluding varnish |
415 |
412 |
$6K |
| D0220 |
Intraoral - periapical first radiographic image |
340 |
336 |
$4K |
| D0230 |
Intraoral - periapical each additional radiographic image |
338 |
334 |
$3K |
| D0272 |
Bitewings - two radiographic images |
43 |
42 |
$981.96 |
| D1330 |
|
16 |
16 |
$12.25 |
| D0603 |
|
296 |
293 |
$0.00 |
| D0602 |
|
100 |
100 |
$0.00 |