| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
72 |
54 |
$2K |
| D0274 |
Bitewings - four radiographic images |
21 |
21 |
$858.13 |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
27 |
12 |
$792.00 |
| D0210 |
Intraoral - complete series of radiographic images |
18 |
18 |
$771.36 |
| D1110 |
Prophylaxis - adult |
13 |
13 |
$620.80 |
| D0120 |
Periodic oral evaluation - established patient |
17 |
17 |
$383.82 |
| D0230 |
Intraoral - periapical each additional radiographic image |
21 |
21 |
$0.00 |
| D0220 |
Intraoral - periapical first radiographic image |
54 |
51 |
$0.00 |