| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0210 |
Intraoral - complete series of radiographic images |
195 |
166 |
$939.25 |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
326 |
124 |
$856.50 |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
185 |
84 |
$828.00 |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
193 |
94 |
$519.00 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
205 |
187 |
$497.00 |
| D2394 |
|
36 |
28 |
$208.50 |
| D1110 |
Prophylaxis - adult |
44 |
41 |
$95.50 |
| D0140 |
Limited oral evaluation - problem focused |
27 |
27 |
$0.00 |
| D1351 |
Sealant - per tooth |
83 |
13 |
$0.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
72 |
29 |
$0.00 |
| D0220 |
Intraoral - periapical first radiographic image |
52 |
36 |
$0.00 |
| D0330 |
Panoramic radiographic image |
29 |
26 |
$0.00 |