| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
181 |
180 |
$5K |
| D0120 |
Periodic oral evaluation - established patient |
166 |
166 |
$5K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
66 |
59 |
$5K |
| D1120 |
Prophylaxis - child |
83 |
82 |
$3K |
| D0274 |
Bitewings - four radiographic images |
166 |
166 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
386 |
362 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
44 |
43 |
$2K |
| D1110 |
Prophylaxis - adult |
45 |
45 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
288 |
263 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
50 |
48 |
$956.00 |