| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
66 |
25 |
$6K |
| D1110 |
Prophylaxis - adult |
82 |
81 |
$4K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
85 |
84 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
21 |
12 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
120 |
115 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
88 |
85 |
$972.66 |
| D9920 |
|
14 |
13 |
$959.00 |
| D0274 |
Bitewings - four radiographic images |
31 |
30 |
$841.74 |
| D0120 |
Periodic oral evaluation - established patient |
38 |
38 |
$765.70 |
| D1120 |
Prophylaxis - child |
13 |
13 |
$435.76 |