| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
158 |
158 |
$8K |
| D0120 |
Periodic oral evaluation - established patient |
250 |
250 |
$7K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
53 |
28 |
$4K |
| D0274 |
Bitewings - four radiographic images |
89 |
89 |
$2K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
18 |
15 |
$2K |
| D0330 |
Panoramic radiographic image |
34 |
34 |
$943.10 |
| D0230 |
Intraoral - periapical each additional radiographic image |
18 |
14 |
$184.60 |