| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
85 |
37 |
$4K |
| D1110 |
Prophylaxis - adult |
140 |
140 |
$3K |
| D0120 |
Periodic oral evaluation - established patient |
83 |
82 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
28 |
16 |
$1K |
| D0210 |
Intraoral - complete series of radiographic images |
34 |
34 |
$1K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
52 |
51 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
298 |
76 |
$970.75 |
| D0220 |
Intraoral - periapical first radiographic image |
95 |
87 |
$352.25 |