| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
206 |
206 |
$11K |
| D0210 |
Intraoral - complete series of radiographic images |
141 |
141 |
$8K |
| D1110 |
Prophylaxis - adult |
127 |
127 |
$7K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
26 |
15 |
$3K |
| D0274 |
Bitewings - four radiographic images |
49 |
49 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
76 |
76 |
$800.47 |
| D0120 |
Periodic oral evaluation - established patient |
15 |
15 |
$477.15 |
| D0230 |
Intraoral - periapical each additional radiographic image |
61 |
61 |
$399.60 |