| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
54 |
25 |
$4K |
| D1120 |
Prophylaxis - child |
78 |
78 |
$3K |
| D0120 |
Periodic oral evaluation - established patient |
137 |
137 |
$3K |
| D1206 |
Topical application of fluoride varnish |
104 |
104 |
$3K |
| D1110 |
Prophylaxis - adult |
42 |
42 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
166 |
162 |
$830.00 |
| D0210 |
Intraoral - complete series of radiographic images |
14 |
14 |
$630.00 |
| D0140 |
Limited oral evaluation - problem focused |
14 |
13 |
$624.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
157 |
154 |
$615.00 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
19 |
19 |
$475.00 |
| D0274 |
Bitewings - four radiographic images |
32 |
32 |
$384.00 |
| D0272 |
Bitewings - two radiographic images |
30 |
30 |
$300.00 |