| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
119 |
70 |
$6K |
| D0120 |
Periodic oral evaluation - established patient |
146 |
146 |
$5K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
67 |
45 |
$4K |
| D0274 |
Bitewings - four radiographic images |
94 |
94 |
$4K |
| D1120 |
Prophylaxis - child |
97 |
97 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
250 |
126 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
137 |
135 |
$2K |
| D1110 |
Prophylaxis - adult |
32 |
32 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
105 |
105 |
$563.85 |