| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
136 |
135 |
$6K |
| D0120 |
Periodic oral evaluation - established patient |
139 |
139 |
$4K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
49 |
34 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
44 |
24 |
$2K |
| D0274 |
Bitewings - four radiographic images |
69 |
69 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
130 |
129 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
26 |
26 |
$950.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
103 |
76 |
$873.00 |
| D0210 |
Intraoral - complete series of radiographic images |
12 |
12 |
$580.00 |
| D0602 |
|
49 |
49 |
$240.00 |
| D0601 |
|
28 |
27 |
$200.00 |
| D1330 |
|
143 |
142 |
$0.00 |
| D1310 |
|
140 |
139 |
$0.00 |