| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
97 |
58 |
$8K |
| D1110 |
Prophylaxis - adult |
182 |
182 |
$8K |
| D0120 |
Periodic oral evaluation - established patient |
252 |
251 |
$7K |
| D1120 |
Prophylaxis - child |
59 |
59 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
81 |
81 |
$2K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
20 |
13 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
26 |
26 |
$1K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
30 |
30 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
33 |
30 |
$974.89 |
| D0220 |
Intraoral - periapical first radiographic image |
41 |
40 |
$586.80 |
| D0274 |
Bitewings - four radiographic images |
12 |
12 |
$399.00 |