| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
872 |
870 |
$48K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
109 |
105 |
$17K |
| D0120 |
Periodic oral evaluation - established patient |
527 |
527 |
$15K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
58 |
56 |
$9K |
| D0210 |
Intraoral - complete series of radiographic images |
199 |
198 |
$9K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
238 |
238 |
$7K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
41 |
40 |
$6K |
| D0274 |
Bitewings - four radiographic images |
181 |
181 |
$5K |
| D2335 |
|
17 |
14 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
307 |
295 |
$4K |
| D2394 |
|
14 |
14 |
$2K |
| D2332 |
|
13 |
13 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
16 |
16 |
$168.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
13 |
12 |
$105.00 |