| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
702 |
702 |
$21K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
339 |
217 |
$15K |
| D0274 |
Bitewings - four radiographic images |
696 |
696 |
$10K |
| D0120 |
Periodic oral evaluation - established patient |
597 |
597 |
$9K |
| D0230 |
Intraoral - periapical each additional radiographic image |
760 |
760 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
635 |
630 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
55 |
40 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
50 |
50 |
$750.00 |
| D0140 |
Limited oral evaluation - problem focused |
12 |
12 |
$180.00 |