| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0230 |
Intraoral - periapical each additional radiographic image |
137 |
135 |
$7K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
24 |
14 |
$3K |
| D2950 |
|
25 |
25 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
243 |
236 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
64 |
64 |
$2K |
| D0120 |
Periodic oral evaluation - established patient |
86 |
86 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
31 |
31 |
$1K |
| D0210 |
Intraoral - complete series of radiographic images |
98 |
98 |
$970.33 |
| D0330 |
Panoramic radiographic image |
12 |
12 |
$597.36 |
| D1110 |
Prophylaxis - adult |
12 |
12 |
$477.12 |