| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
465 |
220 |
$17K |
| D0210 |
Intraoral - complete series of radiographic images |
309 |
306 |
$13K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
87 |
57 |
$8K |
| D1110 |
Prophylaxis - adult |
365 |
362 |
$5K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
161 |
82 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
431 |
426 |
$2K |
| D0120 |
Periodic oral evaluation - established patient |
40 |
40 |
$1K |
| D4341 |
|
31 |
12 |
$378.00 |
| D0274 |
Bitewings - four radiographic images |
55 |
54 |
$136.03 |
| D0220 |
Intraoral - periapical first radiographic image |
111 |
111 |
$115.26 |
| D0230 |
Intraoral - periapical each additional radiographic image |
69 |
56 |
$50.10 |