| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
239 |
125 |
$29K |
| D1110 |
Prophylaxis - adult |
492 |
492 |
$25K |
| D0120 |
Periodic oral evaluation - established patient |
967 |
967 |
$25K |
| D1120 |
Prophylaxis - child |
678 |
678 |
$25K |
| D1206 |
Topical application of fluoride varnish |
890 |
889 |
$16K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
193 |
193 |
$8K |
| D0210 |
Intraoral - complete series of radiographic images |
96 |
96 |
$7K |
| D0274 |
Bitewings - four radiographic images |
153 |
153 |
$5K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
44 |
28 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
210 |
207 |
$3K |
| D0272 |
Bitewings - two radiographic images |
14 |
14 |
$300.00 |