| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
702 |
702 |
$22K |
| D0330 |
Panoramic radiographic image |
558 |
558 |
$19K |
| D0274 |
Bitewings - four radiographic images |
693 |
692 |
$18K |
| D0140 |
Limited oral evaluation - problem focused |
545 |
541 |
$13K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
176 |
126 |
$9K |
| D0120 |
Periodic oral evaluation - established patient |
415 |
415 |
$8K |
| D0220 |
Intraoral - periapical first radiographic image |
1,021 |
1,014 |
$7K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
392 |
392 |
$7K |
| D0230 |
Intraoral - periapical each additional radiographic image |
796 |
720 |
$6K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
75 |
59 |
$4K |
| D2332 |
|
46 |
30 |
$3K |
| D0210 |
Intraoral - complete series of radiographic images |
53 |
53 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
31 |
24 |
$1K |
| D1330 |
|
241 |
240 |
$275.00 |