| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
63 |
32 |
$8K |
| D1120 |
Prophylaxis - child |
131 |
131 |
$5K |
| D0120 |
Periodic oral evaluation - established patient |
136 |
136 |
$4K |
| D1208 |
Topical application of fluoride, excluding varnish |
138 |
137 |
$3K |
| D1110 |
Prophylaxis - adult |
62 |
62 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
27 |
14 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
52 |
52 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
102 |
100 |
$2K |
| D0274 |
Bitewings - four radiographic images |
40 |
40 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
88 |
81 |
$748.80 |
| D0272 |
Bitewings - two radiographic images |
30 |
30 |
$720.00 |
| D0140 |
Limited oral evaluation - problem focused |
20 |
20 |
$692.00 |