| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
952 |
952 |
$55K |
| D0210 |
Intraoral - complete series of radiographic images |
397 |
397 |
$23K |
| D0120 |
Periodic oral evaluation - established patient |
569 |
569 |
$16K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
523 |
523 |
$16K |
| D0274 |
Bitewings - four radiographic images |
435 |
435 |
$12K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
128 |
92 |
$11K |
| D0230 |
Intraoral - periapical each additional radiographic image |
389 |
388 |
$5K |
| D0330 |
Panoramic radiographic image |
302 |
302 |
$5K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
36 |
27 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
188 |
188 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
12 |
12 |
$168.00 |