| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
908 |
908 |
$48K |
| D0330 |
Panoramic radiographic image |
905 |
903 |
$30K |
| D0120 |
Periodic oral evaluation - established patient |
715 |
715 |
$19K |
| D0274 |
Bitewings - four radiographic images |
878 |
876 |
$18K |
| D0220 |
Intraoral - periapical first radiographic image |
1,083 |
1,060 |
$17K |
| D0230 |
Intraoral - periapical each additional radiographic image |
550 |
550 |
$15K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
474 |
474 |
$13K |
| D0140 |
Limited oral evaluation - problem focused |
583 |
582 |
$9K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
51 |
38 |
$4K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
44 |
30 |
$2K |
| D0270 |
|
29 |
29 |
$364.00 |
| D1330 |
|
550 |
550 |
$0.00 |