| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
36 |
14 |
$5K |
| D1110 |
Prophylaxis - adult |
92 |
92 |
$4K |
| D0330 |
Panoramic radiographic image |
64 |
64 |
$3K |
| D0274 |
Bitewings - four radiographic images |
71 |
71 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
43 |
43 |
$2K |
| D0120 |
Periodic oral evaluation - established patient |
28 |
28 |
$640.36 |
| D0140 |
Limited oral evaluation - problem focused |
13 |
13 |
$445.90 |
| D0220 |
Intraoral - periapical first radiographic image |
24 |
24 |
$300.51 |
| D0210 |
Intraoral - complete series of radiographic images |
14 |
13 |
$33.84 |