| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
277 |
276 |
$10K |
| D0274 |
Bitewings - four radiographic images |
272 |
271 |
$5K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
77 |
32 |
$5K |
| D0120 |
Periodic oral evaluation - established patient |
225 |
223 |
$4K |
| D0140 |
Limited oral evaluation - problem focused |
93 |
86 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
393 |
371 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
275 |
274 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
72 |
72 |
$1K |