| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
187 |
101 |
$26K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
91 |
51 |
$16K |
| D1110 |
Prophylaxis - adult |
152 |
152 |
$10K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
108 |
108 |
$6K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
49 |
30 |
$5K |
| D0210 |
Intraoral - complete series of radiographic images |
62 |
62 |
$4K |
| D1208 |
Topical application of fluoride, excluding varnish |
76 |
76 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
17 |
15 |
$803.42 |
| D0120 |
Periodic oral evaluation - established patient |
14 |
14 |
$445.34 |
| D0220 |
Intraoral - periapical first radiographic image |
12 |
12 |
$141.84 |