| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
248 |
236 |
$7K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
269 |
257 |
$5K |
| D0274 |
Bitewings - four radiographic images |
275 |
258 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
209 |
184 |
$3K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
24 |
13 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
180 |
170 |
$824.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
84 |
77 |
$253.00 |
| D0120 |
Periodic oral evaluation - established patient |
23 |
18 |
$196.16 |
| D1330 |
|
12 |
12 |
$0.00 |