| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
37 |
14 |
$5K |
| D1120 |
Prophylaxis - child |
109 |
109 |
$4K |
| D0120 |
Periodic oral evaluation - established patient |
102 |
102 |
$3K |
| D1208 |
Topical application of fluoride, excluding varnish |
103 |
103 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
28 |
28 |
$1K |
| D1110 |
Prophylaxis - adult |
17 |
17 |
$918.00 |
| D0140 |
Limited oral evaluation - problem focused |
28 |
27 |
$634.62 |
| D0274 |
Bitewings - four radiographic images |
18 |
18 |
$490.00 |
| D1206 |
Topical application of fluoride varnish |
12 |
12 |
$300.00 |
| D0220 |
Intraoral - periapical first radiographic image |
12 |
12 |
$211.44 |