| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
698 |
698 |
$26K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
192 |
111 |
$12K |
| D0120 |
Periodic oral evaluation - established patient |
493 |
490 |
$9K |
| D0274 |
Bitewings - four radiographic images |
574 |
574 |
$9K |
| D0210 |
Intraoral - complete series of radiographic images |
117 |
117 |
$6K |
| D0230 |
Intraoral - periapical each additional radiographic image |
752 |
750 |
$5K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
224 |
224 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
767 |
762 |
$5K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
61 |
43 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
26 |
26 |
$374.00 |