| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
77 |
35 |
$10K |
| D1110 |
Prophylaxis - adult |
62 |
62 |
$3K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
15 |
12 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
58 |
58 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
16 |
12 |
$2K |
| D0120 |
Periodic oral evaluation - established patient |
65 |
65 |
$1K |
| D0274 |
Bitewings - four radiographic images |
41 |
41 |
$1K |
| D0210 |
Intraoral - complete series of radiographic images |
12 |
12 |
$902.12 |
| D0220 |
Intraoral - periapical first radiographic image |
43 |
43 |
$529.76 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
12 |
12 |
$463.92 |