| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
124 |
61 |
$15K |
| D1120 |
Prophylaxis - child |
378 |
378 |
$15K |
| D0120 |
Periodic oral evaluation - established patient |
407 |
407 |
$11K |
| D1208 |
Topical application of fluoride, excluding varnish |
416 |
416 |
$10K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
42 |
25 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
205 |
203 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
194 |
119 |
$2K |
| D1110 |
Prophylaxis - adult |
22 |
22 |
$1K |
| D0274 |
Bitewings - four radiographic images |
26 |
26 |
$888.00 |