| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
399 |
399 |
$23K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
132 |
93 |
$11K |
| D0120 |
Periodic oral evaluation - established patient |
351 |
351 |
$10K |
| D0274 |
Bitewings - four radiographic images |
190 |
190 |
$6K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
94 |
66 |
$5K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
86 |
86 |
$3K |
| D0330 |
Panoramic radiographic image |
14 |
14 |
$523.50 |
| D0220 |
Intraoral - periapical first radiographic image |
19 |
19 |
$242.46 |