| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
58 |
26 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
28 |
28 |
$1K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
31 |
30 |
$582.34 |
| D1110 |
Prophylaxis - adult |
15 |
14 |
$411.27 |
| D0120 |
Periodic oral evaluation - established patient |
23 |
23 |
$394.54 |
| D0230 |
Intraoral - periapical each additional radiographic image |
41 |
15 |
$202.25 |
| D0274 |
Bitewings - four radiographic images |
16 |
14 |
$181.00 |
| D0220 |
Intraoral - periapical first radiographic image |
27 |
24 |
$116.25 |