| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
254 |
103 |
$18K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
481 |
481 |
$16K |
| D0210 |
Intraoral - complete series of radiographic images |
154 |
154 |
$9K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
86 |
44 |
$5K |
| D1120 |
Prophylaxis - child |
130 |
130 |
$4K |
| D1110 |
Prophylaxis - adult |
50 |
50 |
$2K |
| D1206 |
Topical application of fluoride varnish |
93 |
93 |
$2K |
| D4346 |
|
13 |
13 |
$2K |
| D0120 |
Periodic oral evaluation - established patient |
46 |
46 |
$968.67 |
| D0274 |
Bitewings - four radiographic images |
12 |
12 |
$314.33 |
| D0220 |
Intraoral - periapical first radiographic image |
12 |
12 |
$137.33 |