| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
223 |
221 |
$11K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
237 |
237 |
$10K |
| D0274 |
Bitewings - four radiographic images |
171 |
171 |
$5K |
| D0230 |
Intraoral - periapical each additional radiographic image |
217 |
216 |
$5K |
| D0350 |
|
139 |
136 |
$5K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
33 |
16 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
302 |
296 |
$4K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
24 |
15 |
$3K |
| D0120 |
Periodic oral evaluation - established patient |
34 |
33 |
$1K |
| D0210 |
Intraoral - complete series of radiographic images |
31 |
31 |
$720.38 |