| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,790 |
1,790 |
$77K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,236 |
304 |
$58K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
767 |
268 |
$49K |
| D0120 |
Periodic oral evaluation - established patient |
1,380 |
1,379 |
$28K |
| D0220 |
Intraoral - periapical first radiographic image |
2,152 |
2,138 |
$19K |
| D0274 |
Bitewings - four radiographic images |
1,023 |
1,023 |
$15K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,024 |
2,013 |
$14K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
396 |
396 |
$9K |
| D2750 |
|
19 |
15 |
$8K |
| D0210 |
Intraoral - complete series of radiographic images |
276 |
276 |
$6K |
| D0272 |
Bitewings - two radiographic images |
239 |
239 |
$5K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
39 |
26 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
29 |
29 |
$417.97 |