| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
113 |
101 |
$6K |
| D0220 |
Intraoral - periapical first radiographic image |
260 |
219 |
$6K |
| D0274 |
Bitewings - four radiographic images |
86 |
76 |
$4K |
| D1110 |
Prophylaxis - adult |
50 |
45 |
$4K |
| D0230 |
Intraoral - periapical each additional radiographic image |
98 |
81 |
$4K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
21 |
14 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
19 |
12 |
$2K |
| D0330 |
Panoramic radiographic image |
13 |
12 |
$1K |