| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0210 |
Intraoral - complete series of radiographic images |
178 |
178 |
$8K |
| D4355 |
|
75 |
75 |
$6K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
58 |
27 |
$5K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
64 |
37 |
$4K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
179 |
179 |
$4K |
| D0140 |
Limited oral evaluation - problem focused |
118 |
111 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
73 |
64 |
$991.00 |
| D1110 |
Prophylaxis - adult |
30 |
30 |
$940.00 |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
26 |
12 |
$806.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
52 |
29 |
$318.00 |
| D0120 |
Periodic oral evaluation - established patient |
12 |
12 |
$314.00 |