| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
49 |
26 |
$6K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
23 |
15 |
$2K |
| D1120 |
Prophylaxis - child |
48 |
48 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
51 |
51 |
$1K |
| D0120 |
Periodic oral evaluation - established patient |
35 |
35 |
$877.03 |
| D0220 |
Intraoral - periapical first radiographic image |
45 |
45 |
$701.84 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
16 |
16 |
$675.00 |
| D1110 |
Prophylaxis - adult |
15 |
15 |
$641.01 |
| D0274 |
Bitewings - four radiographic images |
16 |
16 |
$448.27 |
| D0230 |
Intraoral - periapical each additional radiographic image |
27 |
22 |
$248.20 |