| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
238 |
238 |
$11K |
| D0120 |
Periodic oral evaluation - established patient |
219 |
219 |
$6K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
74 |
38 |
$5K |
| D0140 |
Limited oral evaluation - problem focused |
71 |
66 |
$3K |
| D0210 |
Intraoral - complete series of radiographic images |
53 |
53 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
272 |
266 |
$1K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
40 |
40 |
$1K |
| D0330 |
Panoramic radiographic image |
15 |
15 |
$600.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
110 |
109 |
$459.00 |
| D0274 |
Bitewings - four radiographic images |
24 |
24 |
$288.00 |
| D0270 |
|
12 |
12 |
$60.00 |