| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
106 |
105 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
33 |
27 |
$2K |
| D0120 |
Periodic oral evaluation - established patient |
74 |
73 |
$1K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
19 |
15 |
$1K |
| D0274 |
Bitewings - four radiographic images |
38 |
38 |
$1K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
45 |
45 |
$830.30 |
| D0220 |
Intraoral - periapical first radiographic image |
86 |
85 |
$624.16 |
| D0230 |
Intraoral - periapical each additional radiographic image |
59 |
58 |
$606.56 |
| D0210 |
Intraoral - complete series of radiographic images |
14 |
14 |
$432.71 |