| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
336 |
336 |
$15K |
| D0274 |
Bitewings - four radiographic images |
271 |
271 |
$6K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
84 |
52 |
$4K |
| D0120 |
Periodic oral evaluation - established patient |
186 |
186 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
330 |
328 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
97 |
97 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
275 |
275 |
$1K |
| D0210 |
Intraoral - complete series of radiographic images |
58 |
58 |
$1K |
| D4341 |
|
33 |
13 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
14 |
14 |
$167.72 |
| D1320 |
|
12 |
12 |
$84.00 |