| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
478 |
478 |
$19K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
194 |
63 |
$10K |
| D0120 |
Periodic oral evaluation - established patient |
439 |
439 |
$9K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
97 |
40 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
207 |
206 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
155 |
155 |
$2K |
| D0274 |
Bitewings - four radiographic images |
74 |
74 |
$2K |
| D0330 |
Panoramic radiographic image |
49 |
49 |
$1K |
| D9945 |
|
14 |
14 |
$1K |
| D0210 |
Intraoral - complete series of radiographic images |
48 |
48 |
$791.32 |