| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
181 |
178 |
$9K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
76 |
29 |
$5K |
| D0230 |
Intraoral - periapical each additional radiographic image |
526 |
186 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
44 |
42 |
$2K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
22 |
12 |
$2K |
| D0274 |
Bitewings - four radiographic images |
62 |
61 |
$993.60 |
| D1120 |
Prophylaxis - child |
16 |
16 |
$393.00 |
| D1206 |
Topical application of fluoride varnish |
18 |
17 |
$134.00 |