| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
249 |
249 |
$11K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
106 |
87 |
$8K |
| D0120 |
Periodic oral evaluation - established patient |
261 |
261 |
$6K |
| D0274 |
Bitewings - four radiographic images |
152 |
152 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
252 |
250 |
$3K |
| D0210 |
Intraoral - complete series of radiographic images |
28 |
28 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
201 |
201 |
$1K |
| D0350 |
|
44 |
44 |
$460.68 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
12 |
12 |
$204.00 |