| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
428 |
374 |
$14K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
202 |
79 |
$12K |
| D0330 |
Panoramic radiographic image |
235 |
209 |
$8K |
| D0274 |
Bitewings - four radiographic images |
370 |
329 |
$6K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
90 |
38 |
$5K |
| D2394 |
|
61 |
26 |
$4K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
187 |
157 |
$4K |
| D0120 |
Periodic oral evaluation - established patient |
127 |
116 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
54 |
46 |
$246.40 |