| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,122 |
1,122 |
$50K |
| D0274 |
Bitewings - four radiographic images |
900 |
900 |
$22K |
| D0120 |
Periodic oral evaluation - established patient |
804 |
804 |
$16K |
| D0220 |
Intraoral - periapical first radiographic image |
960 |
940 |
$11K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
110 |
57 |
$8K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
169 |
169 |
$6K |
| D0330 |
Panoramic radiographic image |
155 |
155 |
$6K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
52 |
12 |
$5K |
| D0230 |
Intraoral - periapical each additional radiographic image |
472 |
464 |
$4K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
21 |
13 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
12 |
12 |
$315.90 |