| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,059 |
1,059 |
$38K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
928 |
928 |
$20K |
| D0274 |
Bitewings - four radiographic images |
858 |
858 |
$17K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
204 |
93 |
$10K |
| D0220 |
Intraoral - periapical first radiographic image |
1,046 |
1,042 |
$9K |
| D2751 |
Crown - porcelain fused to predominantly base metal |
19 |
12 |
$8K |
| D0230 |
Intraoral - periapical each additional radiographic image |
911 |
911 |
$4K |
| D0120 |
Periodic oral evaluation - established patient |
167 |
167 |
$3K |
| D0330 |
Panoramic radiographic image |
45 |
45 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
101 |
101 |
$1K |
| D0210 |
Intraoral - complete series of radiographic images |
24 |
24 |
$938.96 |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
18 |
14 |
$538.78 |
| D9430 |
|
12 |
12 |
$150.70 |