| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
115 |
68 |
$16K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
33 |
27 |
$5K |
| D1110 |
Prophylaxis - adult |
113 |
112 |
$5K |
| D0120 |
Periodic oral evaluation - established patient |
137 |
136 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
86 |
83 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
69 |
69 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
179 |
169 |
$2K |
| D0274 |
Bitewings - four radiographic images |
37 |
37 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
40 |
39 |
$961.60 |
| D0210 |
Intraoral - complete series of radiographic images |
13 |
13 |
$748.32 |