| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0210 |
Intraoral - complete series of radiographic images |
444 |
377 |
$22K |
| D1110 |
Prophylaxis - adult |
485 |
441 |
$17K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
395 |
344 |
$15K |
| D0120 |
Periodic oral evaluation - established patient |
269 |
259 |
$7K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
19 |
12 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
19 |
14 |
$1K |
| D0274 |
Bitewings - four radiographic images |
26 |
25 |
$771.65 |
| D0220 |
Intraoral - periapical first radiographic image |
26 |
14 |
$210.40 |
| D8670 |
Periodic orthodontic treatment visit |
37 |
36 |
$0.00 |