| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2752 |
|
119 |
56 |
$39K |
| D1110 |
Prophylaxis - adult |
751 |
751 |
$27K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
579 |
579 |
$12K |
| D0274 |
Bitewings - four radiographic images |
604 |
604 |
$12K |
| D2954 |
|
96 |
69 |
$8K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
161 |
78 |
$8K |
| D0220 |
Intraoral - periapical first radiographic image |
742 |
741 |
$7K |
| D0330 |
Panoramic radiographic image |
169 |
169 |
$4K |
| D0120 |
Periodic oral evaluation - established patient |
193 |
193 |
$4K |
| D0210 |
Intraoral - complete series of radiographic images |
377 |
377 |
$4K |
| D0140 |
Limited oral evaluation - problem focused |
332 |
332 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
668 |
668 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
77 |
34 |
$2K |
| D9110 |
|
49 |
47 |
$724.12 |