| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
118 |
56 |
$6K |
| D1110 |
Prophylaxis - adult |
91 |
91 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
46 |
26 |
$2K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
27 |
19 |
$2K |
| D0120 |
Periodic oral evaluation - established patient |
55 |
55 |
$1K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
37 |
37 |
$687.30 |
| D0210 |
Intraoral - complete series of radiographic images |
15 |
15 |
$637.95 |
| D0274 |
Bitewings - four radiographic images |
21 |
21 |
$539.66 |
| D0220 |
Intraoral - periapical first radiographic image |
68 |
61 |
$514.08 |
| D0230 |
Intraoral - periapical each additional radiographic image |
38 |
38 |
$325.08 |
| D1310 |
|
24 |
24 |
$120.00 |
| D1330 |
|
23 |
23 |
$110.00 |