| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
991 |
988 |
$65K |
| D0210 |
Intraoral - complete series of radiographic images |
466 |
466 |
$22K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
204 |
67 |
$11K |
| D0230 |
Intraoral - periapical each additional radiographic image |
435 |
379 |
$7K |
| D1110 |
Prophylaxis - adult |
57 |
57 |
$5K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
64 |
37 |
$4K |
| D0350 |
|
151 |
80 |
$3K |
| D9430 |
|
37 |
32 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
93 |
90 |
$1K |
| D0274 |
Bitewings - four radiographic images |
41 |
41 |
$864.00 |
| D1120 |
Prophylaxis - child |
15 |
15 |
$787.50 |
| D0272 |
Bitewings - two radiographic images |
48 |
48 |
$564.00 |
| D0330 |
Panoramic radiographic image |
13 |
13 |
$390.00 |
| D9910 |
|
58 |
12 |
$0.00 |