| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
285 |
285 |
$11K |
| D1110 |
Prophylaxis - adult |
171 |
171 |
$8K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
61 |
30 |
$7K |
| D0274 |
Bitewings - four radiographic images |
237 |
237 |
$6K |
| D0220 |
Intraoral - periapical first radiographic image |
419 |
407 |
$6K |
| D0140 |
Limited oral evaluation - problem focused |
109 |
108 |
$4K |
| D0330 |
Panoramic radiographic image |
81 |
81 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
249 |
245 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
17 |
12 |
$1K |
| D0120 |
Periodic oral evaluation - established patient |
14 |
14 |
$374.78 |