| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
298 |
161 |
$34K |
| D1120 |
Prophylaxis - child |
894 |
893 |
$31K |
| D0120 |
Periodic oral evaluation - established patient |
921 |
917 |
$22K |
| D1208 |
Topical application of fluoride, excluding varnish |
979 |
978 |
$20K |
| D0240 |
|
393 |
196 |
$7K |
| D1110 |
Prophylaxis - adult |
128 |
128 |
$6K |
| D0220 |
Intraoral - periapical first radiographic image |
344 |
341 |
$5K |
| D0272 |
Bitewings - two radiographic images |
190 |
190 |
$4K |
| D0230 |
Intraoral - periapical each additional radiographic image |
383 |
263 |
$4K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
67 |
67 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
40 |
40 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
16 |
14 |
$1K |
| D0274 |
Bitewings - four radiographic images |
31 |
31 |
$962.50 |