| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
521 |
515 |
$17K |
| D0274 |
Bitewings - four radiographic images |
307 |
302 |
$8K |
| D0120 |
Periodic oral evaluation - established patient |
357 |
353 |
$7K |
| D0210 |
Intraoral - complete series of radiographic images |
139 |
139 |
$6K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
255 |
253 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
383 |
380 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
293 |
290 |
$2K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
38 |
25 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
37 |
24 |
$2K |
| D9920 |
|
12 |
12 |
$1K |
| D9110 |
|
24 |
24 |
$697.80 |
| D1330 |
|
72 |
71 |
$345.00 |