| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
189 |
123 |
$11K |
| D0274 |
Bitewings - four radiographic images |
256 |
221 |
$6K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
124 |
78 |
$5K |
| D0120 |
Periodic oral evaluation - established patient |
286 |
243 |
$4K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
69 |
69 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
37 |
37 |
$925.00 |
| D1206 |
Topical application of fluoride varnish |
13 |
13 |
$450.19 |
| D0220 |
Intraoral - periapical first radiographic image |
42 |
28 |
$446.00 |