| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
84 |
46 |
$11K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
290 |
288 |
$11K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
83 |
43 |
$9K |
| D1110 |
Prophylaxis - adult |
207 |
207 |
$8K |
| D0330 |
Panoramic radiographic image |
65 |
65 |
$3K |
| D0274 |
Bitewings - four radiographic images |
82 |
82 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
24 |
24 |
$2K |
| D0120 |
Periodic oral evaluation - established patient |
26 |
26 |
$582.92 |
| D0220 |
Intraoral - periapical first radiographic image |
13 |
13 |
$160.16 |