| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
32 |
17 |
$4K |
| D0210 |
Intraoral - complete series of radiographic images |
17 |
17 |
$1K |
| D1206 |
Topical application of fluoride varnish |
41 |
41 |
$1K |
| D0120 |
Periodic oral evaluation - established patient |
35 |
35 |
$978.78 |
| D1120 |
Prophylaxis - child |
22 |
22 |
$880.00 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
19 |
19 |
$811.78 |
| D0274 |
Bitewings - four radiographic images |
12 |
12 |
$413.04 |
| D0220 |
Intraoral - periapical first radiographic image |
17 |
17 |
$273.26 |