| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
75 |
61 |
$3K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
21 |
12 |
$3K |
| D0120 |
Periodic oral evaluation - established patient |
95 |
86 |
$2K |
| D1110 |
Prophylaxis - adult |
46 |
39 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
99 |
91 |
$1K |
| D0274 |
Bitewings - four radiographic images |
41 |
37 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
68 |
62 |
$1K |
| D0210 |
Intraoral - complete series of radiographic images |
12 |
12 |
$955.32 |