| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2335 |
|
254 |
54 |
$37K |
| D1110 |
Prophylaxis - adult |
586 |
550 |
$30K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
152 |
97 |
$9K |
| D2331 |
|
91 |
25 |
$9K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
96 |
62 |
$8K |
| D0120 |
Periodic oral evaluation - established patient |
292 |
280 |
$7K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
149 |
135 |
$6K |
| D0272 |
Bitewings - two radiographic images |
219 |
200 |
$6K |
| D2330 |
|
66 |
25 |
$5K |
| D0140 |
Limited oral evaluation - problem focused |
13 |
13 |
$604.36 |
| D1120 |
Prophylaxis - child |
13 |
13 |
$509.74 |