| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
285 |
281 |
$12K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
58 |
34 |
$5K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
140 |
136 |
$4K |
| D0210 |
Intraoral - complete series of radiographic images |
92 |
90 |
$4K |
| D0140 |
Limited oral evaluation - problem focused |
117 |
98 |
$3K |
| D0120 |
Periodic oral evaluation - established patient |
90 |
90 |
$2K |
| D2394 |
|
23 |
14 |
$2K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
30 |
22 |
$2K |
| D0330 |
Panoramic radiographic image |
27 |
27 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
130 |
123 |
$2K |
| D0274 |
Bitewings - four radiographic images |
43 |
43 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
102 |
57 |
$804.70 |