| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
306 |
306 |
$11K |
| D0120 |
Periodic oral evaluation - established patient |
210 |
210 |
$4K |
| D0274 |
Bitewings - four radiographic images |
167 |
167 |
$4K |
| D0330 |
Panoramic radiographic image |
102 |
102 |
$3K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
39 |
15 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
94 |
94 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
263 |
262 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
142 |
85 |
$753.00 |