| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,719 |
1,718 |
$85K |
| D0120 |
Periodic oral evaluation - established patient |
1,702 |
1,701 |
$45K |
| D0274 |
Bitewings - four radiographic images |
917 |
916 |
$23K |
| D0330 |
Panoramic radiographic image |
304 |
304 |
$11K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
83 |
83 |
$2K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
18 |
12 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
125 |
124 |
$928.90 |
| D0230 |
Intraoral - periapical each additional radiographic image |
45 |
27 |
$238.65 |