| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
914 |
912 |
$49K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
874 |
872 |
$26K |
| D0210 |
Intraoral - complete series of radiographic images |
411 |
408 |
$21K |
| D0274 |
Bitewings - four radiographic images |
249 |
247 |
$7K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
57 |
36 |
$5K |
| D9999 |
Unspecified adjunctive procedure, by report |
16 |
15 |
$2K |
| D0120 |
Periodic oral evaluation - established patient |
55 |
55 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
27 |
12 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
38 |
36 |
$457.12 |
| D0140 |
Limited oral evaluation - problem focused |
13 |
13 |
$182.00 |