| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
259 |
259 |
$11K |
| D0274 |
Bitewings - four radiographic images |
195 |
195 |
$4K |
| D0120 |
Periodic oral evaluation - established patient |
176 |
176 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
337 |
335 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
353 |
237 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
235 |
234 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
126 |
125 |
$2K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
24 |
19 |
$565.47 |
| D0330 |
Panoramic radiographic image |
28 |
27 |
$524.80 |
| D0140 |
Limited oral evaluation - problem focused |
40 |
39 |
$198.93 |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
15 |
12 |
$41.14 |
| D1330 |
|
14 |
14 |
$0.00 |