| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,594 |
1,594 |
$78K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
968 |
500 |
$70K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
784 |
398 |
$39K |
| D0120 |
Periodic oral evaluation - established patient |
1,187 |
1,187 |
$30K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
747 |
746 |
$22K |
| D0274 |
Bitewings - four radiographic images |
781 |
781 |
$21K |
| D0210 |
Intraoral - complete series of radiographic images |
380 |
379 |
$15K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
103 |
70 |
$10K |
| D0330 |
Panoramic radiographic image |
192 |
192 |
$7K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
22 |
12 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
149 |
148 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
12 |
12 |
$172.48 |
| D1999 |
|
464 |
431 |
$0.00 |