| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
650 |
198 |
$26K |
| D1110 |
Prophylaxis - adult |
585 |
583 |
$16K |
| D0230 |
Intraoral - periapical each additional radiographic image |
749 |
641 |
$7K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
339 |
339 |
$5K |
| D0160 |
|
202 |
201 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
995 |
844 |
$4K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
133 |
62 |
$4K |
| D2332 |
|
26 |
13 |
$1K |
| D0120 |
Periodic oral evaluation - established patient |
12 |
12 |
$270.00 |
| D0274 |
Bitewings - four radiographic images |
14 |
14 |
$0.00 |