| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
248 |
197 |
$16K |
| D2750 |
|
19 |
12 |
$8K |
| D0220 |
Intraoral - periapical first radiographic image |
364 |
358 |
$4K |
| D0120 |
Periodic oral evaluation - established patient |
170 |
170 |
$4K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
29 |
25 |
$1K |
| D0270 |
|
106 |
106 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
105 |
101 |
$1K |
| D0274 |
Bitewings - four radiographic images |
12 |
12 |
$273.45 |
| D9110 |
|
12 |
12 |
$265.45 |
| D0230 |
Intraoral - periapical each additional radiographic image |
32 |
32 |
$210.75 |