| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
18 |
13 |
$2K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
16 |
13 |
$2K |
| D1120 |
Prophylaxis - child |
50 |
50 |
$2K |
| D0120 |
Periodic oral evaluation - established patient |
67 |
67 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
45 |
45 |
$1K |
| D0274 |
Bitewings - four radiographic images |
17 |
17 |
$620.00 |
| D0220 |
Intraoral - periapical first radiographic image |
37 |
34 |
$531.00 |