| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
105 |
105 |
$4K |
| D0210 |
Intraoral - complete series of radiographic images |
62 |
62 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
59 |
59 |
$1K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
18 |
12 |
$974.54 |
| D0120 |
Periodic oral evaluation - established patient |
25 |
25 |
$636.00 |
| D0140 |
Limited oral evaluation - problem focused |
23 |
22 |
$582.44 |
| D0220 |
Intraoral - periapical first radiographic image |
59 |
59 |
$539.05 |
| D0274 |
Bitewings - four radiographic images |
13 |
13 |
$259.21 |
| D0230 |
Intraoral - periapical each additional radiographic image |
14 |
13 |
$75.11 |