| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
117 |
65 |
$10K |
| D1208 |
Topical application of fluoride, excluding varnish |
485 |
475 |
$10K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
142 |
81 |
$8K |
| D1110 |
Prophylaxis - adult |
168 |
163 |
$6K |
| D0120 |
Periodic oral evaluation - established patient |
233 |
228 |
$5K |
| D1120 |
Prophylaxis - child |
92 |
89 |
$3K |
| D0274 |
Bitewings - four radiographic images |
55 |
55 |
$1K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
64 |
64 |
$904.82 |
| D0220 |
Intraoral - periapical first radiographic image |
12 |
12 |
$0.00 |