| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
781 |
780 |
$31K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
359 |
108 |
$20K |
| D0120 |
Periodic oral evaluation - established patient |
813 |
811 |
$16K |
| D0330 |
Panoramic radiographic image |
143 |
143 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
196 |
195 |
$2K |
| D0350 |
|
181 |
181 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
63 |
63 |
$1K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
38 |
12 |
$1K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
14 |
12 |
$1K |
| D0274 |
Bitewings - four radiographic images |
41 |
41 |
$820.28 |
| D0230 |
Intraoral - periapical each additional radiographic image |
123 |
123 |
$590.06 |
| D0210 |
Intraoral - complete series of radiographic images |
28 |
28 |
$457.33 |
| D0251 |
|
16 |
16 |
$148.00 |
| D1999 |
|
37 |
35 |
$0.00 |