| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
167 |
71 |
$21K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
96 |
47 |
$9K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
49 |
33 |
$7K |
| D1120 |
Prophylaxis - child |
158 |
158 |
$6K |
| D0120 |
Periodic oral evaluation - established patient |
164 |
164 |
$4K |
| D1208 |
Topical application of fluoride, excluding varnish |
179 |
179 |
$4K |
| D1110 |
Prophylaxis - adult |
66 |
65 |
$3K |
| D0274 |
Bitewings - four radiographic images |
83 |
83 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
139 |
139 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
39 |
38 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
134 |
108 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
17 |
17 |
$654.14 |