| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
211 |
144 |
$22K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
100 |
65 |
$11K |
| D1110 |
Prophylaxis - adult |
191 |
191 |
$10K |
| D0120 |
Periodic oral evaluation - established patient |
293 |
293 |
$7K |
| D0274 |
Bitewings - four radiographic images |
200 |
200 |
$6K |
| D1206 |
Topical application of fluoride varnish |
285 |
285 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
266 |
265 |
$4K |
| D0230 |
Intraoral - periapical each additional radiographic image |
227 |
227 |
$3K |
| D1120 |
Prophylaxis - child |
27 |
27 |
$987.00 |