| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
60 |
44 |
$3K |
| D1110 |
Prophylaxis - adult |
92 |
92 |
$3K |
| D0210 |
Intraoral - complete series of radiographic images |
33 |
33 |
$2K |
| D0120 |
Periodic oral evaluation - established patient |
113 |
113 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
56 |
56 |
$1K |
| D0274 |
Bitewings - four radiographic images |
61 |
61 |
$1K |
| D1208 |
Topical application of fluoride, excluding varnish |
39 |
39 |
$585.00 |
| D0220 |
Intraoral - periapical first radiographic image |
105 |
103 |
$525.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
56 |
54 |
$405.00 |
| D0272 |
Bitewings - two radiographic images |
29 |
29 |
$290.00 |
| D1120 |
Prophylaxis - child |
13 |
13 |
$260.00 |