| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
100 |
100 |
$3K |
| D0274 |
Bitewings - four radiographic images |
102 |
102 |
$3K |
| D0330 |
Panoramic radiographic image |
67 |
67 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
71 |
71 |
$1K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
19 |
14 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
111 |
98 |
$875.38 |
| D0220 |
Intraoral - periapical first radiographic image |
122 |
120 |
$863.38 |
| D1330 |
|
99 |
98 |
$634.16 |
| D1320 |
|
35 |
35 |
$439.50 |
| D1310 |
|
55 |
55 |
$365.66 |
| D0120 |
Periodic oral evaluation - established patient |
13 |
13 |
$258.80 |