| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
942 |
640 |
$37K |
| D0120 |
Periodic oral evaluation - established patient |
687 |
687 |
$14K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
319 |
256 |
$12K |
| D1110 |
Prophylaxis - adult |
356 |
356 |
$7K |
| D1120 |
Prophylaxis - child |
197 |
197 |
$4K |
| D0274 |
Bitewings - four radiographic images |
346 |
346 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
518 |
517 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
323 |
323 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
157 |
157 |
$924.00 |
| D0272 |
Bitewings - two radiographic images |
88 |
88 |
$440.00 |