| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2394 |
|
167 |
130 |
$51K |
| D1110 |
Prophylaxis - adult |
632 |
632 |
$35K |
| D2335 |
|
34 |
27 |
$15K |
| D0120 |
Periodic oral evaluation - established patient |
438 |
438 |
$12K |
| D0220 |
Intraoral - periapical first radiographic image |
482 |
439 |
$6K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
31 |
25 |
$5K |
| D9110 |
|
171 |
165 |
$4K |
| D0330 |
Panoramic radiographic image |
108 |
108 |
$4K |
| D0274 |
Bitewings - four radiographic images |
117 |
117 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
92 |
92 |
$3K |
| D2332 |
|
13 |
12 |
$2K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
12 |
12 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
94 |
91 |
$1K |
| D2951 |
|
16 |
12 |
$1K |
| D0210 |
Intraoral - complete series of radiographic images |
84 |
54 |
$759.72 |
| D0350 |
|
17 |
16 |
$197.40 |
| D3110 |
|
17 |
13 |
$0.00 |