| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
197 |
67 |
$17K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
111 |
111 |
$4K |
| D0120 |
Periodic oral evaluation - established patient |
176 |
176 |
$3K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
24 |
12 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
30 |
15 |
$3K |
| D0274 |
Bitewings - four radiographic images |
159 |
159 |
$3K |
| D0210 |
Intraoral - complete series of radiographic images |
39 |
39 |
$3K |
| D1110 |
Prophylaxis - adult |
12 |
12 |
$782.64 |
| D0220 |
Intraoral - periapical first radiographic image |
25 |
24 |
$245.75 |
| D1208 |
Topical application of fluoride, excluding varnish |
14 |
14 |
$210.00 |
| D1120 |
Prophylaxis - child |
12 |
12 |
$120.00 |