| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
725 |
266 |
$60K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
689 |
246 |
$39K |
| D1120 |
Prophylaxis - child |
309 |
309 |
$13K |
| D0120 |
Periodic oral evaluation - established patient |
388 |
388 |
$10K |
| D1208 |
Topical application of fluoride, excluding varnish |
384 |
384 |
$5K |
| D1110 |
Prophylaxis - adult |
90 |
90 |
$5K |
| D0272 |
Bitewings - two radiographic images |
257 |
257 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
103 |
102 |
$1K |
| D0274 |
Bitewings - four radiographic images |
44 |
44 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
29 |
29 |
$373.80 |