| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
57 |
25 |
$5K |
| D1110 |
Prophylaxis - adult |
89 |
89 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
296 |
269 |
$3K |
| D0120 |
Periodic oral evaluation - established patient |
99 |
99 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
55 |
54 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
18 |
18 |
$825.24 |
| D0274 |
Bitewings - four radiographic images |
12 |
12 |
$367.02 |
| D0230 |
Intraoral - periapical each additional radiographic image |
46 |
42 |
$318.75 |