| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
233 |
233 |
$13K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
74 |
54 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
409 |
399 |
$5K |
| D0230 |
Intraoral - periapical each additional radiographic image |
272 |
272 |
$5K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
140 |
140 |
$4K |
| D0274 |
Bitewings - four radiographic images |
128 |
128 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
59 |
49 |
$3K |
| D0210 |
Intraoral - complete series of radiographic images |
138 |
138 |
$3K |
| D0120 |
Periodic oral evaluation - established patient |
77 |
77 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
98 |
97 |
$1K |