| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
123 |
56 |
$14K |
| D0220 |
Intraoral - periapical first radiographic image |
223 |
213 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
38 |
15 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
179 |
119 |
$2K |
| D0274 |
Bitewings - four radiographic images |
44 |
44 |
$1K |
| D1206 |
Topical application of fluoride varnish |
38 |
38 |
$922.23 |
| D0120 |
Periodic oral evaluation - established patient |
39 |
37 |
$847.45 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
17 |
17 |
$685.80 |
| D1110 |
Prophylaxis - adult |
15 |
12 |
$457.80 |