| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
935 |
916 |
$33K |
| D0274 |
Bitewings - four radiographic images |
451 |
444 |
$11K |
| D0120 |
Periodic oral evaluation - established patient |
605 |
592 |
$9K |
| D0220 |
Intraoral - periapical first radiographic image |
975 |
891 |
$8K |
| D0230 |
Intraoral - periapical each additional radiographic image |
615 |
552 |
$6K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
179 |
168 |
$5K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
17 |
12 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
29 |
28 |
$833.19 |
| D0330 |
Panoramic radiographic image |
16 |
16 |
$809.85 |