| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
552 |
517 |
$11K |
| D1110 |
Prophylaxis - adult |
167 |
159 |
$7K |
| D0330 |
Panoramic radiographic image |
56 |
55 |
$2K |
| D0272 |
Bitewings - two radiographic images |
151 |
144 |
$2K |
| D0120 |
Periodic oral evaluation - established patient |
67 |
66 |
$2K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
28 |
20 |
$638.00 |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
34 |
15 |
$550.00 |
| D0220 |
Intraoral - periapical first radiographic image |
17 |
12 |
$40.00 |