| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
183 |
181 |
$7K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
44 |
19 |
$3K |
| D0210 |
Intraoral - complete series of radiographic images |
65 |
63 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
28 |
14 |
$2K |
| D0274 |
Bitewings - four radiographic images |
30 |
30 |
$660.00 |
| D1110 |
Prophylaxis - adult |
17 |
17 |
$496.00 |
| D1120 |
Prophylaxis - child |
17 |
17 |
$374.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
16 |
16 |
$192.00 |