| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
233 |
229 |
$7K |
| D0274 |
Bitewings - four radiographic images |
222 |
219 |
$6K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
44 |
42 |
$3K |
| D0120 |
Periodic oral evaluation - established patient |
166 |
164 |
$3K |
| D0330 |
Panoramic radiographic image |
72 |
72 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
133 |
132 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
175 |
164 |
$1K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
15 |
14 |
$1K |
| D0210 |
Intraoral - complete series of radiographic images |
26 |
26 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
85 |
80 |
$506.52 |
| D0601 |
|
30 |
30 |
$300.00 |