| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
526 |
523 |
$21K |
| D0120 |
Periodic oral evaluation - established patient |
614 |
611 |
$14K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
232 |
230 |
$9K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
55 |
38 |
$8K |
| D0274 |
Bitewings - four radiographic images |
196 |
196 |
$6K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
25 |
12 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
71 |
69 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
25 |
25 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
127 |
126 |
$2K |