| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
73 |
54 |
$3K |
| D0120 |
Periodic oral evaluation - established patient |
139 |
139 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
88 |
88 |
$2K |
| D1110 |
Prophylaxis - adult |
62 |
62 |
$1K |
| D1120 |
Prophylaxis - child |
54 |
54 |
$1K |
| D0274 |
Bitewings - four radiographic images |
65 |
65 |
$585.00 |
| D0220 |
Intraoral - periapical first radiographic image |
145 |
145 |
$580.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
76 |
76 |
$438.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
50 |
50 |
$300.00 |
| D0272 |
Bitewings - two radiographic images |
39 |
39 |
$195.00 |
| D0270 |
|
28 |
28 |
$84.00 |