| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
156 |
130 |
$12K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
111 |
88 |
$6K |
| D1110 |
Prophylaxis - adult |
61 |
61 |
$3K |
| D0330 |
Panoramic radiographic image |
58 |
57 |
$2K |
| D9110 |
|
76 |
71 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
65 |
63 |
$2K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
14 |
14 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
91 |
90 |
$1K |
| D0120 |
Periodic oral evaluation - established patient |
30 |
30 |
$829.40 |
| D0274 |
Bitewings - four radiographic images |
48 |
46 |
$598.30 |
| D0220 |
Intraoral - periapical first radiographic image |
87 |
83 |
$586.75 |
| D0230 |
Intraoral - periapical each additional radiographic image |
39 |
37 |
$170.00 |
| D9995 |
|
53 |
53 |
$0.00 |