| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
103 |
103 |
$7K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
90 |
40 |
$4K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
66 |
66 |
$569.27 |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
42 |
15 |
$451.54 |
| D0274 |
Bitewings - four radiographic images |
75 |
75 |
$390.47 |
| D1206 |
Topical application of fluoride varnish |
70 |
70 |
$46.34 |
| D0220 |
Intraoral - periapical first radiographic image |
12 |
12 |
$17.41 |