| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,134 |
1,132 |
$42K |
| D0210 |
Intraoral - complete series of radiographic images |
379 |
379 |
$14K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
417 |
417 |
$8K |
| D0274 |
Bitewings - four radiographic images |
319 |
319 |
$6K |
| D0120 |
Periodic oral evaluation - established patient |
304 |
304 |
$6K |
| D0220 |
Intraoral - periapical first radiographic image |
463 |
459 |
$4K |
| D0230 |
Intraoral - periapical each additional radiographic image |
288 |
287 |
$2K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
43 |
26 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
28 |
14 |
$924.00 |