| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
572 |
386 |
$11K |
| D0274 |
Bitewings - four radiographic images |
364 |
231 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
626 |
441 |
$3K |
| D0120 |
Periodic oral evaluation - established patient |
300 |
188 |
$3K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
93 |
28 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
103 |
82 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
400 |
279 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
83 |
56 |
$663.00 |