| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
62 |
62 |
$3K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
25 |
21 |
$3K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
16 |
16 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
23 |
17 |
$1K |
| D0274 |
Bitewings - four radiographic images |
53 |
53 |
$1K |
| D0120 |
Periodic oral evaluation - established patient |
43 |
43 |
$1K |
| D0330 |
Panoramic radiographic image |
42 |
42 |
$977.60 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
24 |
24 |
$720.00 |
| D0210 |
Intraoral - complete series of radiographic images |
32 |
32 |
$505.72 |
| D0220 |
Intraoral - periapical first radiographic image |
17 |
17 |
$223.72 |