| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
94 |
94 |
$876.60 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
84 |
84 |
$820.80 |
| D0120 |
Periodic oral evaluation - established patient |
60 |
60 |
$624.00 |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
14 |
12 |
$240.00 |
| D0274 |
Bitewings - four radiographic images |
52 |
52 |
$147.70 |
| D0230 |
Intraoral - periapical each additional radiographic image |
85 |
85 |
$139.75 |
| D0272 |
Bitewings - two radiographic images |
12 |
12 |
$115.50 |
| D0220 |
Intraoral - periapical first radiographic image |
93 |
93 |
$108.75 |