| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0274 |
Bitewings - four radiographic images |
859 |
850 |
$17K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
323 |
111 |
$17K |
| D0120 |
Periodic oral evaluation - established patient |
309 |
307 |
$14K |
| D1110 |
Prophylaxis - adult |
143 |
143 |
$12K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,951 |
1,112 |
$12K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
57 |
25 |
$4K |
| D1120 |
Prophylaxis - child |
86 |
86 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
46 |
45 |
$2K |
| D0350 |
|
45 |
13 |
$432.00 |