| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
318 |
316 |
$14K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
89 |
55 |
$5K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
125 |
68 |
$5K |
| D0120 |
Periodic oral evaluation - established patient |
56 |
56 |
$1K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
48 |
47 |
$1K |
| D0210 |
Intraoral - complete series of radiographic images |
14 |
14 |
$600.00 |
| D0274 |
Bitewings - four radiographic images |
12 |
12 |
$288.00 |