| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0999 |
Unspecified diagnostic procedure, by report |
345 |
303 |
$25K |
| D1110 |
Prophylaxis - adult |
451 |
451 |
$15K |
| D0120 |
Periodic oral evaluation - established patient |
369 |
369 |
$6K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
101 |
87 |
$5K |
| D0274 |
Bitewings - four radiographic images |
276 |
276 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
391 |
389 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
296 |
295 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
57 |
57 |
$1K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
14 |
12 |
$630.00 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
14 |
14 |
$378.00 |