| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0210 |
Intraoral - complete series of radiographic images |
187 |
84 |
$742.46 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
90 |
90 |
$529.10 |
| D0274 |
Bitewings - four radiographic images |
141 |
141 |
$425.88 |
| D0220 |
Intraoral - periapical first radiographic image |
193 |
170 |
$0.00 |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
181 |
56 |
$0.00 |
| D2740 |
Crown - porcelain/ceramic |
39 |
26 |
$0.00 |
| D1110 |
Prophylaxis - adult |
119 |
119 |
$0.00 |
| D2950 |
|
57 |
39 |
$0.00 |
| D9920 |
|
18 |
12 |
$0.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
18 |
14 |
$0.00 |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
66 |
29 |
$0.00 |
| D0120 |
Periodic oral evaluation - established patient |
14 |
14 |
$0.00 |