| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
84 |
59 |
$5K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
39 |
29 |
$3K |
| D0120 |
Periodic oral evaluation - established patient |
43 |
43 |
$2K |
| D1110 |
Prophylaxis - adult |
29 |
29 |
$1K |
| D1120 |
Prophylaxis - child |
31 |
31 |
$1K |
| D1208 |
Topical application of fluoride, excluding varnish |
54 |
54 |
$206.89 |
| D0272 |
Bitewings - two radiographic images |
13 |
13 |
$60.65 |
| D0274 |
Bitewings - four radiographic images |
29 |
29 |
$0.00 |