| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0210 |
Intraoral - complete series of radiographic images |
102 |
97 |
$5K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
204 |
194 |
$5K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
98 |
27 |
$5K |
| D1110 |
Prophylaxis - adult |
96 |
93 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
46 |
16 |
$1K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
27 |
13 |
$1K |
| D0274 |
Bitewings - four radiographic images |
53 |
51 |
$880.00 |
| D0120 |
Periodic oral evaluation - established patient |
28 |
28 |
$424.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
94 |
37 |
$340.00 |
| D0140 |
Limited oral evaluation - problem focused |
17 |
14 |
$313.12 |
| D0220 |
Intraoral - periapical first radiographic image |
58 |
55 |
$265.00 |
| D1120 |
Prophylaxis - child |
13 |
13 |
$260.00 |