| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
123 |
123 |
$7K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
101 |
101 |
$3K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
16 |
14 |
$2K |
| D0274 |
Bitewings - four radiographic images |
65 |
65 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
80 |
80 |
$1K |
| D0120 |
Periodic oral evaluation - established patient |
38 |
38 |
$981.36 |
| D0140 |
Limited oral evaluation - problem focused |
18 |
18 |
$315.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
12 |
12 |
$179.41 |