| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
331 |
152 |
$20K |
| D0120 |
Periodic oral evaluation - established patient |
378 |
377 |
$9K |
| D1120 |
Prophylaxis - child |
178 |
177 |
$8K |
| D1110 |
Prophylaxis - adult |
179 |
179 |
$8K |
| D1208 |
Topical application of fluoride, excluding varnish |
275 |
275 |
$7K |
| D0274 |
Bitewings - four radiographic images |
280 |
278 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
39 |
24 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
333 |
329 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
284 |
282 |
$900.00 |
| D0210 |
Intraoral - complete series of radiographic images |
12 |
12 |
$495.00 |
| D1206 |
Topical application of fluoride varnish |
12 |
12 |
$375.00 |
| D0601 |
|
14 |
14 |
$140.00 |