| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
402 |
402 |
$12K |
| D0120 |
Periodic oral evaluation - established patient |
459 |
458 |
$10K |
| D0330 |
Panoramic radiographic image |
153 |
153 |
$5K |
| D1120 |
Prophylaxis - child |
97 |
97 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
135 |
135 |
$3K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
35 |
25 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
42 |
25 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
248 |
245 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
33 |
33 |
$1K |
| D0274 |
Bitewings - four radiographic images |
62 |
62 |
$777.00 |
| D0272 |
Bitewings - two radiographic images |
62 |
62 |
$518.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
99 |
99 |
$300.00 |