| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
39 |
25 |
$4K |
| D1120 |
Prophylaxis - child |
95 |
95 |
$4K |
| D0120 |
Periodic oral evaluation - established patient |
113 |
113 |
$3K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
21 |
12 |
$3K |
| D1208 |
Topical application of fluoride, excluding varnish |
101 |
101 |
$2K |
| D0274 |
Bitewings - four radiographic images |
47 |
47 |
$2K |
| D1110 |
Prophylaxis - adult |
31 |
31 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
67 |
67 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
61 |
59 |
$534.00 |