| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
40 |
25 |
$4K |
| D1120 |
Prophylaxis - child |
78 |
78 |
$3K |
| D0120 |
Periodic oral evaluation - established patient |
70 |
70 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
44 |
42 |
$2K |
| D1110 |
Prophylaxis - adult |
26 |
26 |
$1K |
| D1208 |
Topical application of fluoride, excluding varnish |
47 |
47 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
75 |
71 |
$1K |
| D0210 |
Intraoral - complete series of radiographic images |
13 |
13 |
$855.90 |
| D0230 |
Intraoral - periapical each additional radiographic image |
83 |
63 |
$577.30 |
| D0140 |
Limited oral evaluation - problem focused |
17 |
14 |
$547.34 |