| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,117 |
1,115 |
$53K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
523 |
370 |
$33K |
| D0210 |
Intraoral - complete series of radiographic images |
450 |
447 |
$19K |
| D0120 |
Periodic oral evaluation - established patient |
769 |
766 |
$18K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
469 |
469 |
$11K |
| D0274 |
Bitewings - four radiographic images |
343 |
343 |
$9K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
172 |
112 |
$5K |
| D0230 |
Intraoral - periapical each additional radiographic image |
387 |
386 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
396 |
394 |
$4K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
48 |
38 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
14 |
14 |
$157.11 |