| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
310 |
91 |
$13K |
| D1120 |
Prophylaxis - child |
160 |
160 |
$5K |
| D0120 |
Periodic oral evaluation - established patient |
192 |
192 |
$5K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
35 |
20 |
$2K |
| D0272 |
Bitewings - two radiographic images |
125 |
125 |
$2K |
| D1110 |
Prophylaxis - adult |
40 |
40 |
$2K |
| D1206 |
Topical application of fluoride varnish |
48 |
48 |
$1K |
| D1208 |
Topical application of fluoride, excluding varnish |
111 |
111 |
$1K |
| D0274 |
Bitewings - four radiographic images |
32 |
32 |
$790.40 |
| D0145 |
Oral evaluation for a patient under three years of age |
15 |
15 |
$356.25 |
| D0220 |
Intraoral - periapical first radiographic image |
32 |
32 |
$233.70 |
| D0240 |
|
17 |
17 |
$228.00 |