| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
359 |
128 |
$28K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
85 |
47 |
$10K |
| D1110 |
Prophylaxis - adult |
229 |
217 |
$10K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
232 |
223 |
$9K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
80 |
37 |
$5K |
| D0272 |
Bitewings - two radiographic images |
274 |
261 |
$5K |
| D0120 |
Periodic oral evaluation - established patient |
122 |
117 |
$3K |
| D1120 |
Prophylaxis - child |
63 |
63 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
100 |
98 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
38 |
38 |
$842.38 |
| D0220 |
Intraoral - periapical first radiographic image |
40 |
24 |
$323.18 |
| D0999 |
Unspecified diagnostic procedure, by report |
872 |
420 |
$0.00 |