| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
119 |
119 |
$4K |
| D1110 |
Prophylaxis - adult |
65 |
65 |
$3K |
| D0210 |
Intraoral - complete series of radiographic images |
82 |
82 |
$3K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
30 |
19 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
25 |
13 |
$1K |
| D0330 |
Panoramic radiographic image |
35 |
35 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
71 |
67 |
$1K |
| D0274 |
Bitewings - four radiographic images |
36 |
36 |
$949.58 |
| D0350 |
|
56 |
56 |
$736.96 |
| D0220 |
Intraoral - periapical first radiographic image |
34 |
34 |
$417.64 |