| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
115 |
115 |
$5K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
64 |
30 |
$3K |
| D0120 |
Periodic oral evaluation - established patient |
114 |
114 |
$3K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
26 |
15 |
$1K |
| D0210 |
Intraoral - complete series of radiographic images |
30 |
30 |
$1K |
| D0274 |
Bitewings - four radiographic images |
13 |
13 |
$486.72 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
20 |
20 |
$400.00 |
| D0220 |
Intraoral - periapical first radiographic image |
13 |
12 |
$112.32 |