| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
299 |
299 |
$13K |
| D0120 |
Periodic oral evaluation - established patient |
316 |
316 |
$9K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
53 |
27 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
459 |
453 |
$2K |
| D0274 |
Bitewings - four radiographic images |
156 |
156 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
356 |
354 |
$1K |
| D1120 |
Prophylaxis - child |
12 |
12 |
$540.00 |
| D0140 |
Limited oral evaluation - problem focused |
43 |
42 |
$516.00 |
| D0272 |
Bitewings - two radiographic images |
26 |
26 |
$260.00 |