| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
170 |
170 |
$6K |
| D0120 |
Periodic oral evaluation - established patient |
241 |
241 |
$4K |
| D0230 |
Intraoral - periapical each additional radiographic image |
183 |
183 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
242 |
240 |
$2K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
23 |
16 |
$2K |
| D0274 |
Bitewings - four radiographic images |
62 |
62 |
$1K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
14 |
13 |
$613.78 |