| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
243 |
243 |
$16K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
155 |
72 |
$10K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
145 |
58 |
$8K |
| D0350 |
|
571 |
136 |
$5K |
| D0210 |
Intraoral - complete series of radiographic images |
67 |
67 |
$3K |
| D1208 |
Topical application of fluoride, excluding varnish |
163 |
163 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
198 |
75 |
$2K |
| D0274 |
Bitewings - four radiographic images |
25 |
25 |
$480.60 |