| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
260 |
100 |
$32K |
| D1110 |
Prophylaxis - adult |
497 |
485 |
$23K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
170 |
56 |
$16K |
| D0120 |
Periodic oral evaluation - established patient |
337 |
332 |
$8K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
154 |
153 |
$6K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
33 |
12 |
$5K |
| D0274 |
Bitewings - four radiographic images |
63 |
63 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
13 |
13 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
30 |
29 |
$365.40 |