| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
131 |
70 |
$12K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
125 |
61 |
$8K |
| D0120 |
Periodic oral evaluation - established patient |
215 |
210 |
$5K |
| D4355 |
|
65 |
62 |
$4K |
| D1110 |
Prophylaxis - adult |
51 |
51 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
110 |
109 |
$2K |
| D0274 |
Bitewings - four radiographic images |
43 |
42 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
51 |
46 |
$633.46 |
| D1120 |
Prophylaxis - child |
15 |
15 |
$388.05 |