| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
27 |
13 |
$4K |
| D1110 |
Prophylaxis - adult |
47 |
45 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
48 |
47 |
$2K |
| D0120 |
Periodic oral evaluation - established patient |
56 |
53 |
$1K |
| D0210 |
Intraoral - complete series of radiographic images |
14 |
14 |
$981.87 |
| D0220 |
Intraoral - periapical first radiographic image |
50 |
49 |
$644.28 |
| D0274 |
Bitewings - four radiographic images |
19 |
19 |
$573.29 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
13 |
13 |
$457.50 |