| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
39 |
16 |
$5K |
| D0120 |
Periodic oral evaluation - established patient |
50 |
50 |
$1K |
| D1120 |
Prophylaxis - child |
27 |
27 |
$1K |
| D1208 |
Topical application of fluoride, excluding varnish |
39 |
39 |
$975.00 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
38 |
38 |
$826.67 |
| D1110 |
Prophylaxis - adult |
14 |
14 |
$726.60 |
| D0220 |
Intraoral - periapical first radiographic image |
38 |
38 |
$587.56 |
| D0230 |
Intraoral - periapical each additional radiographic image |
33 |
32 |
$286.20 |