| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
43 |
22 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
33 |
19 |
$1K |
| D1110 |
Prophylaxis - adult |
31 |
31 |
$963.90 |
| D0210 |
Intraoral - complete series of radiographic images |
18 |
18 |
$723.01 |
| D0274 |
Bitewings - four radiographic images |
24 |
24 |
$635.04 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
27 |
27 |
$491.40 |
| D0120 |
Periodic oral evaluation - established patient |
17 |
17 |
$302.40 |
| D0220 |
Intraoral - periapical first radiographic image |
23 |
23 |
$173.88 |
| D0230 |
Intraoral - periapical each additional radiographic image |
20 |
20 |
$151.20 |