| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
689 |
217 |
$43K |
| D9920 |
|
725 |
660 |
$36K |
| D1110 |
Prophylaxis - adult |
552 |
551 |
$21K |
| D0120 |
Periodic oral evaluation - established patient |
1,135 |
1,122 |
$19K |
| D1120 |
Prophylaxis - child |
385 |
378 |
$13K |
| D1208 |
Topical application of fluoride, excluding varnish |
590 |
590 |
$11K |
| D9630 |
|
825 |
808 |
$11K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
163 |
83 |
$7K |
| D0230 |
Intraoral - periapical each additional radiographic image |
724 |
622 |
$7K |
| D0220 |
Intraoral - periapical first radiographic image |
762 |
732 |
$7K |
| D0274 |
Bitewings - four radiographic images |
212 |
211 |
$5K |
| D1206 |
Topical application of fluoride varnish |
119 |
119 |
$3K |