| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
199 |
199 |
$7K |
| D0274 |
Bitewings - four radiographic images |
213 |
213 |
$6K |
| D0120 |
Periodic oral evaluation - established patient |
198 |
198 |
$4K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
51 |
30 |
$3K |
| D9110 |
|
96 |
96 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
241 |
239 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
27 |
20 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
169 |
95 |
$1K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
15 |
13 |
$975.00 |
| D0330 |
Panoramic radiographic image |
14 |
14 |
$518.00 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
24 |
24 |
$478.90 |