| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
351 |
350 |
$15K |
| D0120 |
Periodic oral evaluation - established patient |
156 |
155 |
$4K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
122 |
122 |
$3K |
| D0210 |
Intraoral - complete series of radiographic images |
85 |
85 |
$3K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
42 |
26 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
29 |
13 |
$1K |
| D0274 |
Bitewings - four radiographic images |
27 |
27 |
$624.00 |