| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
155 |
151 |
$6K |
| D0120 |
Periodic oral evaluation - established patient |
118 |
115 |
$3K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
33 |
12 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
342 |
329 |
$1K |
| D0274 |
Bitewings - four radiographic images |
117 |
115 |
$1K |
| D0330 |
Panoramic radiographic image |
29 |
29 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
204 |
195 |
$474.00 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
15 |
15 |
$375.00 |