| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
112 |
43 |
$5K |
| D0210 |
Intraoral - complete series of radiographic images |
85 |
85 |
$3K |
| D0120 |
Periodic oral evaluation - established patient |
171 |
171 |
$3K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
43 |
26 |
$3K |
| D1110 |
Prophylaxis - adult |
71 |
71 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
55 |
55 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
94 |
92 |
$910.10 |
| D0230 |
Intraoral - periapical each additional radiographic image |
31 |
31 |
$257.10 |
| D0274 |
Bitewings - four radiographic images |
13 |
13 |
$255.40 |