| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
39 |
15 |
$2K |
| D1120 |
Prophylaxis - child |
105 |
105 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
99 |
99 |
$1K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
55 |
55 |
$1K |
| D0272 |
Bitewings - two radiographic images |
76 |
76 |
$740.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
55 |
51 |
$275.00 |
| D0220 |
Intraoral - periapical first radiographic image |
53 |
53 |
$265.00 |
| D0120 |
Periodic oral evaluation - established patient |
15 |
15 |
$239.12 |
| D1206 |
Topical application of fluoride varnish |
12 |
12 |
$180.00 |