| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
455 |
446 |
$23K |
| D0120 |
Periodic oral evaluation - established patient |
282 |
276 |
$6K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
147 |
146 |
$6K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
75 |
52 |
$5K |
| D0274 |
Bitewings - four radiographic images |
78 |
77 |
$2K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
20 |
13 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
13 |
13 |
$897.00 |
| D0220 |
Intraoral - periapical first radiographic image |
50 |
49 |
$648.00 |
| D0140 |
Limited oral evaluation - problem focused |
13 |
13 |
$478.00 |