| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1330 |
|
80 |
80 |
$4K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
72 |
35 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
49 |
49 |
$2K |
| D0120 |
Periodic oral evaluation - established patient |
112 |
112 |
$2K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
20 |
13 |
$928.58 |
| D0274 |
Bitewings - four radiographic images |
59 |
59 |
$636.25 |
| D1110 |
Prophylaxis - adult |
87 |
87 |
$559.07 |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
19 |
13 |
$476.10 |
| D1208 |
Topical application of fluoride, excluding varnish |
84 |
84 |
$28.26 |
| D0251 |
|
12 |
12 |
$24.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
110 |
110 |
$0.00 |
| D0210 |
Intraoral - complete series of radiographic images |
45 |
45 |
$0.00 |
| D0220 |
Intraoral - periapical first radiographic image |
115 |
115 |
$0.00 |
| D1120 |
Prophylaxis - child |
25 |
25 |
$0.00 |