| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
359 |
358 |
$12K |
| D0120 |
Periodic oral evaluation - established patient |
294 |
293 |
$5K |
| D0210 |
Intraoral - complete series of radiographic images |
78 |
78 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
148 |
148 |
$3K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
51 |
31 |
$2K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
42 |
26 |
$2K |
| D0274 |
Bitewings - four radiographic images |
99 |
98 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
278 |
270 |
$2K |
| D0330 |
Panoramic radiographic image |
26 |
26 |
$845.34 |
| D0230 |
Intraoral - periapical each additional radiographic image |
94 |
51 |
$712.01 |
| D0140 |
Limited oral evaluation - problem focused |
25 |
25 |
$503.64 |
| D1330 |
|
39 |
39 |
$75.00 |