| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
422 |
281 |
$51K |
| D1120 |
Prophylaxis - child |
858 |
858 |
$31K |
| D0120 |
Periodic oral evaluation - established patient |
960 |
960 |
$23K |
| D1206 |
Topical application of fluoride varnish |
1,044 |
1,044 |
$23K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
184 |
134 |
$15K |
| D0220 |
Intraoral - periapical first radiographic image |
753 |
747 |
$11K |
| D1110 |
Prophylaxis - adult |
193 |
193 |
$8K |
| D0230 |
Intraoral - periapical each additional radiographic image |
632 |
559 |
$5K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
83 |
83 |
$3K |
| D0274 |
Bitewings - four radiographic images |
91 |
91 |
$3K |
| D0272 |
Bitewings - two radiographic images |
38 |
38 |
$875.00 |