| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
324 |
318 |
$17K |
| D0220 |
Intraoral - periapical first radiographic image |
1,087 |
771 |
$15K |
| D0120 |
Periodic oral evaluation - established patient |
155 |
155 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
43 |
24 |
$3K |
| D0210 |
Intraoral - complete series of radiographic images |
27 |
26 |
$2K |
| D9110 |
|
50 |
45 |
$2K |
| D0274 |
Bitewings - four radiographic images |
43 |
43 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
143 |
77 |
$671.00 |
| D0140 |
Limited oral evaluation - problem focused |
16 |
12 |
$546.00 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
14 |
13 |
$480.00 |