| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0210 |
Intraoral - complete series of radiographic images |
183 |
171 |
$14K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
95 |
59 |
$13K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
300 |
277 |
$11K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
78 |
42 |
$8K |
| D0120 |
Periodic oral evaluation - established patient |
106 |
90 |
$2K |
| D1110 |
Prophylaxis - adult |
42 |
38 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
42 |
37 |
$501.72 |
| D0140 |
Limited oral evaluation - problem focused |
13 |
13 |
$422.37 |