| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
221 |
221 |
$7K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
107 |
53 |
$6K |
| D0274 |
Bitewings - four radiographic images |
171 |
171 |
$5K |
| D0120 |
Periodic oral evaluation - established patient |
174 |
174 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
75 |
40 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
111 |
111 |
$2K |
| D9110 |
|
65 |
65 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
226 |
221 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
157 |
156 |
$1K |
| D1330 |
|
12 |
12 |
$60.00 |