| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
65 |
41 |
$8K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
44 |
28 |
$4K |
| D1110 |
Prophylaxis - adult |
78 |
78 |
$3K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
14 |
13 |
$2K |
| D0120 |
Periodic oral evaluation - established patient |
95 |
95 |
$2K |
| D0274 |
Bitewings - four radiographic images |
52 |
52 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
45 |
45 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
49 |
49 |
$615.04 |