| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
138 |
129 |
$6K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
99 |
88 |
$4K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
27 |
13 |
$4K |
| D0120 |
Periodic oral evaluation - established patient |
152 |
146 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
271 |
242 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
172 |
150 |
$3K |
| D0274 |
Bitewings - four radiographic images |
49 |
44 |
$1K |
| D0210 |
Intraoral - complete series of radiographic images |
12 |
12 |
$955.32 |
| D0140 |
Limited oral evaluation - problem focused |
12 |
12 |
$393.72 |