| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
208 |
208 |
$12K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
73 |
58 |
$10K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
90 |
48 |
$9K |
| D0120 |
Periodic oral evaluation - established patient |
154 |
153 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
207 |
201 |
$4K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
44 |
43 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
30 |
26 |
$1K |
| D0210 |
Intraoral - complete series of radiographic images |
17 |
17 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
115 |
96 |
$1K |
| D0274 |
Bitewings - four radiographic images |
27 |
27 |
$1K |