| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D4355 |
|
190 |
190 |
$16K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
207 |
107 |
$8K |
| D0210 |
Intraoral - complete series of radiographic images |
287 |
287 |
$8K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
81 |
42 |
$6K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
217 |
215 |
$2K |
| D1110 |
Prophylaxis - adult |
38 |
38 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
288 |
284 |
$1K |
| D1330 |
|
453 |
442 |
$645.74 |
| D1206 |
Topical application of fluoride varnish |
273 |
266 |
$640.80 |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
24 |
14 |
$155.00 |
| D0120 |
Periodic oral evaluation - established patient |
38 |
38 |
$135.35 |
| D0274 |
Bitewings - four radiographic images |
13 |
13 |
$76.35 |
| D0220 |
Intraoral - periapical first radiographic image |
52 |
36 |
$48.96 |
| D1208 |
Topical application of fluoride, excluding varnish |
73 |
72 |
$11.05 |
| D0230 |
Intraoral - periapical each additional radiographic image |
20 |
12 |
$0.00 |