| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
39 |
27 |
$5K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
87 |
82 |
$4K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
32 |
16 |
$3K |
| D0330 |
Panoramic radiographic image |
66 |
66 |
$3K |
| D1110 |
Prophylaxis - adult |
64 |
63 |
$3K |
| D0274 |
Bitewings - four radiographic images |
72 |
72 |
$2K |
| D0120 |
Periodic oral evaluation - established patient |
41 |
41 |
$906.10 |
| D0220 |
Intraoral - periapical first radiographic image |
30 |
30 |
$364.20 |