| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0140 |
Limited oral evaluation - problem focused |
183 |
179 |
$6K |
| D1110 |
Prophylaxis - adult |
151 |
151 |
$5K |
| D0330 |
Panoramic radiographic image |
121 |
120 |
$5K |
| D0230 |
Intraoral - periapical each additional radiographic image |
443 |
112 |
$5K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
104 |
104 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
179 |
171 |
$2K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
22 |
13 |
$2K |
| D0120 |
Periodic oral evaluation - established patient |
100 |
100 |
$2K |
| D0274 |
Bitewings - four radiographic images |
111 |
111 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
21 |
12 |
$2K |
| D9110 |
|
29 |
28 |
$1K |