| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2752 |
|
40 |
28 |
$23K |
| D1110 |
Prophylaxis - adult |
315 |
315 |
$15K |
| D0274 |
Bitewings - four radiographic images |
166 |
166 |
$3K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
42 |
25 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
267 |
266 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
60 |
60 |
$2K |
| D0330 |
Panoramic radiographic image |
38 |
38 |
$1K |
| D0120 |
Periodic oral evaluation - established patient |
39 |
39 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
145 |
145 |
$1K |