| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
673 |
673 |
$21K |
| D0120 |
Periodic oral evaluation - established patient |
710 |
710 |
$12K |
| D0274 |
Bitewings - four radiographic images |
568 |
568 |
$9K |
| D0220 |
Intraoral - periapical first radiographic image |
899 |
891 |
$7K |
| D0230 |
Intraoral - periapical each additional radiographic image |
513 |
507 |
$3K |
| D2140 |
|
46 |
24 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
38 |
14 |
$1K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
25 |
12 |
$673.00 |