| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
168 |
168 |
$5K |
| D0274 |
Bitewings - four radiographic images |
161 |
161 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
80 |
72 |
$2K |
| D0120 |
Periodic oral evaluation - established patient |
78 |
78 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
198 |
183 |
$1K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
26 |
13 |
$1K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
52 |
52 |
$938.20 |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
16 |
12 |
$932.10 |
| D0330 |
Panoramic radiographic image |
12 |
12 |
$386.70 |
| D1330 |
|
27 |
27 |
$147.16 |