| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
22 |
16 |
$5K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
48 |
48 |
$4K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
21 |
12 |
$4K |
| D1206 |
Topical application of fluoride varnish |
73 |
73 |
$3K |
| D1120 |
Prophylaxis - child |
54 |
54 |
$3K |
| D0274 |
Bitewings - four radiographic images |
50 |
50 |
$3K |
| D0330 |
Panoramic radiographic image |
26 |
26 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
94 |
94 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
30 |
30 |
$3K |
| D0120 |
Periodic oral evaluation - established patient |
24 |
24 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
14 |
14 |
$1K |
| D0272 |
Bitewings - two radiographic images |
14 |
14 |
$630.00 |