| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
63 |
28 |
$4K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
112 |
112 |
$4K |
| D0274 |
Bitewings - four radiographic images |
76 |
74 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
169 |
165 |
$2K |
| D1120 |
Prophylaxis - child |
39 |
39 |
$1K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
16 |
12 |
$921.47 |
| D0120 |
Periodic oral evaluation - established patient |
39 |
39 |
$845.52 |
| D1206 |
Topical application of fluoride varnish |
43 |
43 |
$744.50 |
| D0230 |
Intraoral - periapical each additional radiographic image |
39 |
31 |
$462.80 |
| D1208 |
Topical application of fluoride, excluding varnish |
12 |
12 |
$209.25 |