| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
637 |
634 |
$37K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
409 |
148 |
$27K |
| D0120 |
Periodic oral evaluation - established patient |
659 |
656 |
$24K |
| D0230 |
Intraoral - periapical each additional radiographic image |
5,377 |
1,240 |
$22K |
| D0274 |
Bitewings - four radiographic images |
628 |
624 |
$13K |
| D1120 |
Prophylaxis - child |
432 |
430 |
$12K |
| D1110 |
Prophylaxis - adult |
44 |
44 |
$3K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
23 |
13 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
26 |
26 |
$312.00 |
| D0272 |
Bitewings - two radiographic images |
13 |
13 |
$156.00 |