| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
266 |
148 |
$13K |
| D1110 |
Prophylaxis - adult |
349 |
333 |
$11K |
| D0120 |
Periodic oral evaluation - established patient |
525 |
502 |
$8K |
| D0274 |
Bitewings - four radiographic images |
345 |
328 |
$6K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
75 |
39 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
638 |
518 |
$3K |
| D1208 |
Topical application of fluoride, excluding varnish |
214 |
209 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
631 |
598 |
$3K |
| D1120 |
Prophylaxis - child |
62 |
60 |
$1K |
| D0272 |
Bitewings - two radiographic images |
63 |
61 |
$600.00 |