| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
712 |
679 |
$24K |
| D0274 |
Bitewings - four radiographic images |
460 |
446 |
$13K |
| D0220 |
Intraoral - periapical first radiographic image |
842 |
793 |
$12K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
221 |
203 |
$9K |
| D0230 |
Intraoral - periapical each additional radiographic image |
683 |
567 |
$8K |
| D0120 |
Periodic oral evaluation - established patient |
341 |
324 |
$7K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
64 |
41 |
$7K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
47 |
25 |
$6K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
21 |
12 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
42 |
40 |
$1K |