| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
180 |
74 |
$13K |
| D1110 |
Prophylaxis - adult |
130 |
130 |
$4K |
| D1206 |
Topical application of fluoride varnish |
207 |
207 |
$4K |
| D0120 |
Periodic oral evaluation - established patient |
175 |
175 |
$4K |
| D0274 |
Bitewings - four radiographic images |
164 |
164 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
126 |
123 |
$3K |
| D1120 |
Prophylaxis - child |
78 |
78 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
67 |
67 |
$1K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
14 |
12 |
$767.00 |
| D0220 |
Intraoral - periapical first radiographic image |
103 |
98 |
$589.00 |
| D0272 |
Bitewings - two radiographic images |
14 |
14 |
$169.00 |