| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
99 |
31 |
$8K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
55 |
16 |
$6K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
52 |
12 |
$3K |
| D9310 |
|
26 |
26 |
$2K |
| D1110 |
Prophylaxis - adult |
17 |
17 |
$986.00 |
| D0120 |
Periodic oral evaluation - established patient |
22 |
22 |
$638.00 |
| D0274 |
Bitewings - four radiographic images |
20 |
20 |
$580.00 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
14 |
14 |
$406.00 |
| D0220 |
Intraoral - periapical first radiographic image |
24 |
24 |
$330.00 |