| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
677 |
677 |
$39K |
| D0120 |
Periodic oral evaluation - established patient |
266 |
266 |
$8K |
| D0210 |
Intraoral - complete series of radiographic images |
116 |
116 |
$7K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
208 |
208 |
$6K |
| D0220 |
Intraoral - periapical first radiographic image |
228 |
226 |
$3K |
| D0274 |
Bitewings - four radiographic images |
96 |
96 |
$3K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
19 |
14 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
123 |
123 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
31 |
30 |
$434.00 |