| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
91 |
49 |
$12K |
| D0220 |
Intraoral - periapical first radiographic image |
309 |
289 |
$4K |
| D0230 |
Intraoral - periapical each additional radiographic image |
217 |
209 |
$4K |
| D0120 |
Periodic oral evaluation - established patient |
152 |
149 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
25 |
12 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
52 |
52 |
$2K |
| D1110 |
Prophylaxis - adult |
36 |
36 |
$1K |
| D0274 |
Bitewings - four radiographic images |
24 |
24 |
$675.36 |
| D0140 |
Limited oral evaluation - problem focused |
17 |
14 |
$557.77 |