| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
77 |
47 |
$5K |
| D1120 |
Prophylaxis - child |
94 |
92 |
$4K |
| D0120 |
Periodic oral evaluation - established patient |
96 |
94 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
72 |
70 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
193 |
190 |
$996.80 |
| D1110 |
Prophylaxis - adult |
38 |
38 |
$965.20 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
44 |
44 |
$905.15 |
| D0230 |
Intraoral - periapical each additional radiographic image |
193 |
175 |
$649.80 |
| D0274 |
Bitewings - four radiographic images |
13 |
13 |
$219.70 |