| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
804 |
804 |
$65K |
| D0230 |
Intraoral - periapical each additional radiographic image |
3,178 |
1,832 |
$30K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
418 |
418 |
$23K |
| D0120 |
Periodic oral evaluation - established patient |
436 |
436 |
$20K |
| D0272 |
Bitewings - two radiographic images |
1,093 |
1,093 |
$13K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
213 |
116 |
$11K |
| D0220 |
Intraoral - periapical first radiographic image |
780 |
725 |
$9K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
20 |
15 |
$1K |
| D1120 |
Prophylaxis - child |
12 |
12 |
$360.00 |