| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
179 |
94 |
$21K |
| D1120 |
Prophylaxis - child |
219 |
219 |
$8K |
| D0120 |
Periodic oral evaluation - established patient |
240 |
240 |
$6K |
| D1206 |
Topical application of fluoride varnish |
197 |
197 |
$5K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
53 |
25 |
$4K |
| D1110 |
Prophylaxis - adult |
57 |
57 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
135 |
134 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
26 |
26 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
106 |
66 |
$922.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
41 |
41 |
$847.43 |
| D0210 |
Intraoral - complete series of radiographic images |
13 |
13 |
$719.92 |
| D0274 |
Bitewings - four radiographic images |
12 |
12 |
$420.00 |