| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
689 |
688 |
$40K |
| D0120 |
Periodic oral evaluation - established patient |
500 |
499 |
$15K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
104 |
98 |
$14K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
220 |
220 |
$6K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
55 |
52 |
$6K |
| D0210 |
Intraoral - complete series of radiographic images |
94 |
94 |
$5K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
15 |
12 |
$2K |
| D0274 |
Bitewings - four radiographic images |
57 |
57 |
$2K |
| D1999 |
|
63 |
50 |
$0.00 |