| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
244 |
109 |
$18K |
| D1110 |
Prophylaxis - adult |
534 |
529 |
$18K |
| D0140 |
Limited oral evaluation - problem focused |
637 |
488 |
$10K |
| D0120 |
Periodic oral evaluation - established patient |
351 |
345 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
561 |
506 |
$4K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
100 |
100 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
547 |
204 |
$3K |
| D0210 |
Intraoral - complete series of radiographic images |
37 |
37 |
$3K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
26 |
14 |
$2K |