| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
189 |
77 |
$32K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
191 |
109 |
$26K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
165 |
159 |
$6K |
| D0210 |
Intraoral - complete series of radiographic images |
88 |
88 |
$6K |
| D2394 |
|
27 |
12 |
$5K |
| D0120 |
Periodic oral evaluation - established patient |
175 |
175 |
$4K |
| D0274 |
Bitewings - four radiographic images |
78 |
78 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
162 |
156 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
35 |
34 |
$1K |
| D1110 |
Prophylaxis - adult |
12 |
12 |
$481.92 |