| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0230 |
Intraoral - periapical each additional radiographic image |
3,777 |
1,058 |
$16K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
198 |
107 |
$13K |
| D0220 |
Intraoral - periapical first radiographic image |
571 |
526 |
$7K |
| D1208 |
Topical application of fluoride, excluding varnish |
504 |
502 |
$7K |
| D0120 |
Periodic oral evaluation - established patient |
76 |
76 |
$5K |
| D0274 |
Bitewings - four radiographic images |
196 |
195 |
$4K |
| D1110 |
Prophylaxis - adult |
43 |
43 |
$4K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
20 |
12 |
$2K |
| D1120 |
Prophylaxis - child |
13 |
13 |
$682.50 |