| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
89 |
81 |
$3K |
| D0274 |
Bitewings - four radiographic images |
93 |
81 |
$1K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
17 |
14 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
151 |
131 |
$874.89 |
| D0140 |
Limited oral evaluation - problem focused |
50 |
45 |
$749.63 |
| D0120 |
Periodic oral evaluation - established patient |
51 |
48 |
$672.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
119 |
93 |
$526.36 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
28 |
26 |
$487.00 |