| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
71 |
60 |
$5K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
63 |
49 |
$3K |
| D0120 |
Periodic oral evaluation - established patient |
75 |
75 |
$2K |
| D0274 |
Bitewings - four radiographic images |
87 |
87 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
78 |
77 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
221 |
209 |
$1K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
15 |
13 |
$1K |
| D1120 |
Prophylaxis - child |
30 |
30 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
153 |
152 |
$973.08 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
35 |
35 |
$912.80 |
| D1110 |
Prophylaxis - adult |
16 |
16 |
$725.70 |