| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
67 |
24 |
$7K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
57 |
57 |
$3K |
| D1110 |
Prophylaxis - adult |
30 |
29 |
$2K |
| D1120 |
Prophylaxis - child |
28 |
28 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
50 |
49 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
70 |
69 |
$1K |
| D0274 |
Bitewings - four radiographic images |
27 |
27 |
$1K |
| D0120 |
Periodic oral evaluation - established patient |
18 |
17 |
$506.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
16 |
16 |
$256.00 |