| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
34 |
16 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
147 |
142 |
$3K |
| D0120 |
Periodic oral evaluation - established patient |
83 |
83 |
$2K |
| D1206 |
Topical application of fluoride varnish |
51 |
51 |
$1K |
| D0274 |
Bitewings - four radiographic images |
25 |
25 |
$840.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
80 |
41 |
$726.00 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
13 |
13 |
$611.00 |
| D0140 |
Limited oral evaluation - problem focused |
12 |
12 |
$552.00 |
| D1120 |
Prophylaxis - child |
12 |
12 |
$479.00 |