| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
96 |
96 |
$4K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
39 |
25 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
55 |
52 |
$2K |
| D0120 |
Periodic oral evaluation - established patient |
67 |
66 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
173 |
167 |
$820.00 |
| D0140 |
Limited oral evaluation - problem focused |
36 |
32 |
$643.00 |
| D0274 |
Bitewings - four radiographic images |
47 |
45 |
$519.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
59 |
59 |
$201.00 |