| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
218 |
214 |
$11K |
| D0330 |
Panoramic radiographic image |
149 |
147 |
$10K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
75 |
50 |
$5K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
158 |
157 |
$5K |
| D0274 |
Bitewings - four radiographic images |
92 |
88 |
$3K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
18 |
12 |
$1K |
| D0120 |
Periodic oral evaluation - established patient |
40 |
38 |
$929.50 |
| D0220 |
Intraoral - periapical first radiographic image |
29 |
25 |
$249.00 |