| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
120 |
16 |
$4K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
94 |
14 |
$3K |
| D1110 |
Prophylaxis - adult |
34 |
19 |
$821.34 |
| D0274 |
Bitewings - four radiographic images |
42 |
23 |
$542.36 |
| D1206 |
Topical application of fluoride varnish |
38 |
21 |
$451.00 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
28 |
16 |
$428.48 |
| D0220 |
Intraoral - periapical first radiographic image |
33 |
18 |
$230.58 |
| D0230 |
Intraoral - periapical each additional radiographic image |
30 |
16 |
$157.60 |
| D1330 |
|
35 |
20 |
$0.00 |