| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
282 |
282 |
$9K |
| D0120 |
Periodic oral evaluation - established patient |
267 |
267 |
$5K |
| D0210 |
Intraoral - complete series of radiographic images |
92 |
92 |
$4K |
| D0274 |
Bitewings - four radiographic images |
144 |
144 |
$4K |
| D9110 |
|
109 |
108 |
$3K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
56 |
32 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
52 |
38 |
$2K |
| D0330 |
Panoramic radiographic image |
61 |
61 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
107 |
107 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
175 |
172 |
$1K |
| D4910 |
|
12 |
12 |
$332.64 |
| D0230 |
Intraoral - periapical each additional radiographic image |
17 |
17 |
$128.96 |