| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
233 |
105 |
$15K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
176 |
84 |
$10K |
| D1110 |
Prophylaxis - adult |
179 |
178 |
$6K |
| D0210 |
Intraoral - complete series of radiographic images |
75 |
75 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
160 |
160 |
$3K |
| D2332 |
|
39 |
12 |
$2K |
| D0120 |
Periodic oral evaluation - established patient |
59 |
59 |
$1K |
| D1330 |
|
93 |
93 |
$845.20 |
| D1310 |
|
93 |
93 |
$831.55 |
| D0274 |
Bitewings - four radiographic images |
30 |
30 |
$637.84 |