| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
82 |
44 |
$10K |
| D1120 |
Prophylaxis - child |
132 |
132 |
$5K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
73 |
73 |
$3K |
| D1208 |
Topical application of fluoride, excluding varnish |
125 |
125 |
$3K |
| D0120 |
Periodic oral evaluation - established patient |
109 |
109 |
$3K |
| D1110 |
Prophylaxis - adult |
41 |
41 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
47 |
45 |
$2K |
| D0274 |
Bitewings - four radiographic images |
35 |
35 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
67 |
67 |
$1K |
| D0210 |
Intraoral - complete series of radiographic images |
12 |
12 |
$912.12 |
| D0230 |
Intraoral - periapical each additional radiographic image |
44 |
42 |
$385.20 |
| D0272 |
Bitewings - two radiographic images |
13 |
13 |
$325.00 |