| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,166 |
1,164 |
$46K |
| D0120 |
Periodic oral evaluation - established patient |
1,366 |
1,358 |
$27K |
| D0274 |
Bitewings - four radiographic images |
734 |
733 |
$15K |
| D0210 |
Intraoral - complete series of radiographic images |
333 |
333 |
$11K |
| D0220 |
Intraoral - periapical first radiographic image |
938 |
931 |
$8K |
| D0230 |
Intraoral - periapical each additional radiographic image |
849 |
845 |
$6K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
118 |
83 |
$5K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
81 |
68 |
$5K |
| D0140 |
Limited oral evaluation - problem focused |
51 |
51 |
$494.32 |