| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
197 |
193 |
$3K |
| D0210 |
Intraoral - complete series of radiographic images |
77 |
74 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
300 |
259 |
$988.04 |
| D1110 |
Prophylaxis - adult |
56 |
54 |
$674.85 |
| D0274 |
Bitewings - four radiographic images |
16 |
13 |
$466.44 |
| D0230 |
Intraoral - periapical each additional radiographic image |
90 |
68 |
$348.72 |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
96 |
57 |
$0.00 |
| D0120 |
Periodic oral evaluation - established patient |
15 |
15 |
$0.00 |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
53 |
36 |
$0.00 |
| D2950 |
|
24 |
15 |
$0.00 |