| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
141 |
140 |
$8K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
96 |
64 |
$6K |
| D0120 |
Periodic oral evaluation - established patient |
125 |
124 |
$3K |
| D0210 |
Intraoral - complete series of radiographic images |
48 |
48 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
63 |
63 |
$2K |
| D0274 |
Bitewings - four radiographic images |
52 |
51 |
$2K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
15 |
13 |
$1K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
14 |
12 |
$598.40 |
| D0220 |
Intraoral - periapical first radiographic image |
32 |
32 |
$324.00 |