| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
99 |
39 |
$11K |
| D1120 |
Prophylaxis - child |
202 |
202 |
$7K |
| D0120 |
Periodic oral evaluation - established patient |
274 |
274 |
$7K |
| D1110 |
Prophylaxis - adult |
128 |
127 |
$6K |
| D0220 |
Intraoral - periapical first radiographic image |
294 |
288 |
$5K |
| D1208 |
Topical application of fluoride, excluding varnish |
201 |
201 |
$4K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
32 |
12 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
268 |
175 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
38 |
36 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
27 |
27 |
$1K |
| D0272 |
Bitewings - two radiographic images |
33 |
33 |
$701.50 |