| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
687 |
675 |
$19K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
122 |
94 |
$8K |
| D1110 |
Prophylaxis - adult |
161 |
151 |
$7K |
| D0274 |
Bitewings - four radiographic images |
254 |
243 |
$5K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
36 |
25 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
423 |
400 |
$2K |
| D1120 |
Prophylaxis - child |
30 |
28 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
100 |
95 |
$621.99 |
| D0140 |
Limited oral evaluation - problem focused |
12 |
12 |
$207.72 |