| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
306 |
272 |
$9K |
| D0274 |
Bitewings - four radiographic images |
236 |
205 |
$5K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
67 |
39 |
$4K |
| D0120 |
Periodic oral evaluation - established patient |
230 |
207 |
$4K |
| D9110 |
|
128 |
113 |
$3K |
| D1330 |
|
305 |
270 |
$2K |
| D1310 |
|
305 |
270 |
$2K |
| D0330 |
Panoramic radiographic image |
50 |
42 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
157 |
138 |
$1K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
50 |
38 |
$749.35 |
| D0230 |
Intraoral - periapical each additional radiographic image |
13 |
12 |
$110.96 |