| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
34 |
18 |
$5K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
19 |
14 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
20 |
20 |
$1K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
23 |
22 |
$867.56 |
| D1110 |
Prophylaxis - adult |
16 |
15 |
$642.40 |
| D0140 |
Limited oral evaluation - problem focused |
13 |
13 |
$426.53 |
| D0274 |
Bitewings - four radiographic images |
13 |
13 |
$369.33 |
| D0120 |
Periodic oral evaluation - established patient |
16 |
16 |
$350.08 |
| D0220 |
Intraoral - periapical first radiographic image |
24 |
24 |
$288.48 |
| D0230 |
Intraoral - periapical each additional radiographic image |
12 |
12 |
$240.40 |