| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
51 |
27 |
$4K |
| D1110 |
Prophylaxis - adult |
30 |
30 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
15 |
15 |
$1K |
| D0120 |
Periodic oral evaluation - established patient |
49 |
49 |
$921.03 |
| D1208 |
Topical application of fluoride, excluding varnish |
114 |
114 |
$665.44 |
| D0220 |
Intraoral - periapical first radiographic image |
141 |
140 |
$424.04 |
| D1330 |
|
113 |
113 |
$324.81 |
| D0274 |
Bitewings - four radiographic images |
84 |
84 |
$87.84 |
| D0230 |
Intraoral - periapical each additional radiographic image |
124 |
114 |
$45.00 |
| D1120 |
Prophylaxis - child |
15 |
15 |
$0.00 |