| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
575 |
575 |
$31K |
| D0120 |
Periodic oral evaluation - established patient |
402 |
402 |
$11K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
19 |
15 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
101 |
101 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
142 |
142 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
13 |
13 |
$602.98 |
| D0230 |
Intraoral - periapical each additional radiographic image |
52 |
52 |
$344.99 |
| D0274 |
Bitewings - four radiographic images |
12 |
12 |
$327.12 |