| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,408 |
1,407 |
$57K |
| D0120 |
Periodic oral evaluation - established patient |
1,011 |
1,010 |
$22K |
| D0210 |
Intraoral - complete series of radiographic images |
596 |
596 |
$18K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,109 |
1,103 |
$13K |
| D0220 |
Intraoral - periapical first radiographic image |
1,263 |
1,251 |
$13K |
| D0274 |
Bitewings - four radiographic images |
499 |
498 |
$11K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
88 |
43 |
$5K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
109 |
109 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
76 |
27 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
12 |
12 |
$129.61 |