| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
277 |
272 |
$18K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
283 |
278 |
$16K |
| D0330 |
Panoramic radiographic image |
271 |
266 |
$12K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
42 |
31 |
$5K |
| D0120 |
Periodic oral evaluation - established patient |
72 |
72 |
$2K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
15 |
13 |
$2K |
| D0272 |
Bitewings - two radiographic images |
49 |
48 |
$787.68 |
| D0220 |
Intraoral - periapical first radiographic image |
60 |
55 |
$657.98 |