| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
194 |
85 |
$17K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
113 |
41 |
$6K |
| D1110 |
Prophylaxis - adult |
115 |
113 |
$5K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
120 |
119 |
$4K |
| D0120 |
Periodic oral evaluation - established patient |
159 |
157 |
$3K |
| D1120 |
Prophylaxis - child |
78 |
77 |
$3K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
23 |
13 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
86 |
85 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
127 |
121 |
$1K |
| D0274 |
Bitewings - four radiographic images |
75 |
74 |
$999.16 |
| D0230 |
Intraoral - periapical each additional radiographic image |
116 |
76 |
$249.99 |