| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
125 |
105 |
$10K |
| D1110 |
Prophylaxis - adult |
293 |
293 |
$9K |
| D0120 |
Periodic oral evaluation - established patient |
254 |
253 |
$5K |
| D0210 |
Intraoral - complete series of radiographic images |
270 |
269 |
$4K |
| D0230 |
Intraoral - periapical each additional radiographic image |
279 |
277 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
144 |
144 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
314 |
312 |
$3K |
| D1120 |
Prophylaxis - child |
59 |
58 |
$2K |
| D0274 |
Bitewings - four radiographic images |
26 |
26 |
$453.60 |
| D0272 |
Bitewings - two radiographic images |
29 |
29 |
$350.40 |
| D0140 |
Limited oral evaluation - problem focused |
17 |
17 |
$138.50 |