| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
438 |
252 |
$43K |
| D1110 |
Prophylaxis - adult |
507 |
499 |
$21K |
| D0274 |
Bitewings - four radiographic images |
372 |
371 |
$8K |
| D0220 |
Intraoral - periapical first radiographic image |
809 |
753 |
$8K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
286 |
284 |
$6K |
| D0230 |
Intraoral - periapical each additional radiographic image |
640 |
621 |
$6K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
101 |
58 |
$5K |
| D0210 |
Intraoral - complete series of radiographic images |
408 |
374 |
$3K |
| D0120 |
Periodic oral evaluation - established patient |
117 |
115 |
$3K |
| D9110 |
|
79 |
67 |
$876.33 |