| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,672 |
1,670 |
$87K |
| D0120 |
Periodic oral evaluation - established patient |
1,585 |
1,585 |
$42K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
196 |
85 |
$20K |
| D0274 |
Bitewings - four radiographic images |
532 |
532 |
$14K |
| D0210 |
Intraoral - complete series of radiographic images |
315 |
312 |
$14K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
261 |
261 |
$7K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
78 |
42 |
$7K |
| D0330 |
Panoramic radiographic image |
139 |
139 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
40 |
39 |
$458.61 |
| D1330 |
|
41 |
40 |
$0.00 |
| D1999 |
|
67 |
58 |
$0.00 |