| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,922 |
1,920 |
$50K |
| D0120 |
Periodic oral evaluation - established patient |
1,789 |
1,789 |
$38K |
| D0140 |
Limited oral evaluation - problem focused |
721 |
671 |
$16K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
363 |
232 |
$16K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,871 |
1,859 |
$16K |
| D0274 |
Bitewings - four radiographic images |
1,642 |
1,641 |
$15K |
| D0220 |
Intraoral - periapical first radiographic image |
2,272 |
2,191 |
$10K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
172 |
117 |
$9K |
| D2394 |
|
32 |
27 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
38 |
28 |
$1K |
| D0210 |
Intraoral - complete series of radiographic images |
38 |
38 |
$1K |
| D0270 |
|
97 |
88 |
$294.50 |