| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
734 |
733 |
$39K |
| D0120 |
Periodic oral evaluation - established patient |
477 |
477 |
$13K |
| D0210 |
Intraoral - complete series of radiographic images |
122 |
122 |
$7K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
63 |
42 |
$5K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
139 |
139 |
$4K |
| D0274 |
Bitewings - four radiographic images |
185 |
185 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
338 |
338 |
$4K |
| D0230 |
Intraoral - periapical each additional radiographic image |
192 |
190 |
$1K |
| D0330 |
Panoramic radiographic image |
55 |
55 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
14 |
14 |
$109.20 |