| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,223 |
1,222 |
$45K |
| D0274 |
Bitewings - four radiographic images |
761 |
761 |
$15K |
| D0120 |
Periodic oral evaluation - established patient |
745 |
745 |
$15K |
| D0220 |
Intraoral - periapical first radiographic image |
1,077 |
1,074 |
$10K |
| D0210 |
Intraoral - complete series of radiographic images |
155 |
155 |
$6K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
259 |
259 |
$6K |
| D0230 |
Intraoral - periapical each additional radiographic image |
912 |
912 |
$5K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
23 |
12 |
$1K |
| D1999 |
|
16 |
12 |
$0.00 |