| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
854 |
197 |
$48K |
| D1110 |
Prophylaxis - adult |
470 |
470 |
$19K |
| D0120 |
Periodic oral evaluation - established patient |
555 |
555 |
$13K |
| D0220 |
Intraoral - periapical first radiographic image |
1,033 |
1,006 |
$5K |
| D1206 |
Topical application of fluoride varnish |
95 |
95 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
752 |
752 |
$2K |
| D0274 |
Bitewings - four radiographic images |
241 |
241 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
26 |
26 |
$1K |
| D1120 |
Prophylaxis - child |
32 |
32 |
$1K |
| D0272 |
Bitewings - two radiographic images |
61 |
61 |
$560.00 |
| D9110 |
|
12 |
12 |
$360.00 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
16 |
16 |
$275.00 |