| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,322 |
1,322 |
$62K |
| D0274 |
Bitewings - four radiographic images |
895 |
895 |
$21K |
| D0220 |
Intraoral - periapical first radiographic image |
1,304 |
1,294 |
$15K |
| D0120 |
Periodic oral evaluation - established patient |
621 |
621 |
$15K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
594 |
594 |
$15K |
| D0230 |
Intraoral - periapical each additional radiographic image |
996 |
994 |
$7K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
121 |
68 |
$5K |
| D0140 |
Limited oral evaluation - problem focused |
223 |
218 |
$3K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
13 |
12 |
$971.82 |