| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
156 |
41 |
$13K |
| D1110 |
Prophylaxis - adult |
475 |
469 |
$12K |
| D0210 |
Intraoral - complete series of radiographic images |
186 |
181 |
$8K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
459 |
446 |
$7K |
| D0140 |
Limited oral evaluation - problem focused |
241 |
232 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
777 |
739 |
$3K |
| D0274 |
Bitewings - four radiographic images |
306 |
300 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
787 |
480 |
$2K |
| D0120 |
Periodic oral evaluation - established patient |
127 |
127 |
$2K |