| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
179 |
179 |
$5K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
72 |
33 |
$4K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
96 |
96 |
$2K |
| D0120 |
Periodic oral evaluation - established patient |
85 |
85 |
$2K |
| D0274 |
Bitewings - four radiographic images |
141 |
141 |
$1K |
| D0330 |
Panoramic radiographic image |
62 |
62 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
37 |
34 |
$854.00 |
| D0220 |
Intraoral - periapical first radiographic image |
158 |
143 |
$542.50 |
| D0230 |
Intraoral - periapical each additional radiographic image |
130 |
127 |
$337.00 |
| D0603 |
|
198 |
198 |
$315.00 |
| D1330 |
|
47 |
47 |
$0.00 |