| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
371 |
371 |
$21K |
| D0210 |
Intraoral - complete series of radiographic images |
65 |
65 |
$4K |
| D0120 |
Periodic oral evaluation - established patient |
85 |
85 |
$2K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
27 |
12 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
67 |
67 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
52 |
52 |
$686.00 |
| D0274 |
Bitewings - four radiographic images |
24 |
24 |
$667.00 |
| D0140 |
Limited oral evaluation - problem focused |
13 |
13 |
$182.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
12 |
12 |
$147.00 |