| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
259 |
110 |
$13K |
| D0274 |
Bitewings - four radiographic images |
370 |
369 |
$9K |
| D1110 |
Prophylaxis - adult |
230 |
230 |
$8K |
| D1208 |
Topical application of fluoride, excluding varnish |
457 |
457 |
$7K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
160 |
71 |
$7K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
237 |
236 |
$6K |
| D0210 |
Intraoral - complete series of radiographic images |
94 |
94 |
$4K |
| D1120 |
Prophylaxis - child |
99 |
99 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
39 |
37 |
$1K |
| D0120 |
Periodic oral evaluation - established patient |
29 |
29 |
$547.17 |