| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
401 |
400 |
$13K |
| D0120 |
Periodic oral evaluation - established patient |
322 |
322 |
$6K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
63 |
36 |
$4K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
45 |
29 |
$3K |
| D0274 |
Bitewings - four radiographic images |
73 |
72 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
102 |
102 |
$2K |
| D0330 |
Panoramic radiographic image |
54 |
54 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
230 |
224 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
102 |
90 |
$1K |
| D0210 |
Intraoral - complete series of radiographic images |
29 |
29 |
$1K |
| D1330 |
|
197 |
197 |
$360.00 |