| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,129 |
1,079 |
$40K |
| D0120 |
Periodic oral evaluation - established patient |
1,133 |
1,074 |
$26K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
195 |
186 |
$8K |
| D0274 |
Bitewings - four radiographic images |
241 |
232 |
$7K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
39 |
26 |
$4K |
| D0330 |
Panoramic radiographic image |
76 |
68 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
241 |
227 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
89 |
87 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
55 |
24 |
$583.44 |