| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
48 |
16 |
$6K |
| D1208 |
Topical application of fluoride, excluding varnish |
206 |
201 |
$4K |
| D0120 |
Periodic oral evaluation - established patient |
135 |
135 |
$4K |
| D1110 |
Prophylaxis - adult |
31 |
31 |
$2K |
| D1120 |
Prophylaxis - child |
39 |
39 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
103 |
101 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
13 |
13 |
$813.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
70 |
52 |
$808.03 |
| D0274 |
Bitewings - four radiographic images |
15 |
15 |
$529.39 |