| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
21 |
13 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
102 |
101 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
24 |
12 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
146 |
136 |
$2K |
| D1110 |
Prophylaxis - adult |
39 |
38 |
$2K |
| D0274 |
Bitewings - four radiographic images |
73 |
73 |
$1K |
| D0210 |
Intraoral - complete series of radiographic images |
12 |
12 |
$829.20 |
| D0230 |
Intraoral - periapical each additional radiographic image |
64 |
63 |
$335.75 |