| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
129 |
62 |
$11K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
108 |
67 |
$10K |
| D1208 |
Topical application of fluoride, excluding varnish |
119 |
119 |
$332.64 |
| D0120 |
Periodic oral evaluation - established patient |
235 |
235 |
$0.00 |
| D0140 |
Limited oral evaluation - problem focused |
16 |
16 |
$0.00 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
63 |
63 |
$0.00 |
| D0220 |
Intraoral - periapical first radiographic image |
124 |
116 |
$0.00 |
| D1110 |
Prophylaxis - adult |
228 |
228 |
$0.00 |
| D0274 |
Bitewings - four radiographic images |
168 |
168 |
$0.00 |