| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
160 |
94 |
$14K |
| D1110 |
Prophylaxis - adult |
251 |
251 |
$10K |
| D0120 |
Periodic oral evaluation - established patient |
320 |
317 |
$6K |
| D0274 |
Bitewings - four radiographic images |
200 |
199 |
$5K |
| D1206 |
Topical application of fluoride varnish |
195 |
195 |
$4K |
| D1120 |
Prophylaxis - child |
117 |
116 |
$4K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
114 |
114 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
81 |
81 |
$753.58 |
| D0272 |
Bitewings - two radiographic images |
28 |
28 |
$429.56 |
| D0602 |
|
12 |
12 |
$0.00 |