| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
70 |
68 |
$4K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
20 |
14 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
43 |
43 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
31 |
31 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
120 |
117 |
$1K |
| D0274 |
Bitewings - four radiographic images |
48 |
48 |
$1K |
| D0120 |
Periodic oral evaluation - established patient |
36 |
36 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
56 |
56 |
$367.36 |