| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
78 |
52 |
$9K |
| D1120 |
Prophylaxis - child |
167 |
167 |
$5K |
| D1206 |
Topical application of fluoride varnish |
170 |
170 |
$4K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
35 |
26 |
$3K |
| D0120 |
Periodic oral evaluation - established patient |
107 |
107 |
$3K |
| D0272 |
Bitewings - two radiographic images |
59 |
59 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
13 |
13 |
$845.00 |
| D0220 |
Intraoral - periapical first radiographic image |
12 |
12 |
$240.00 |