| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,222 |
1,200 |
$43K |
| D0210 |
Intraoral - complete series of radiographic images |
271 |
268 |
$13K |
| D0120 |
Periodic oral evaluation - established patient |
829 |
813 |
$13K |
| D0274 |
Bitewings - four radiographic images |
629 |
613 |
$10K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
212 |
211 |
$7K |
| D0220 |
Intraoral - periapical first radiographic image |
733 |
714 |
$5K |
| D0230 |
Intraoral - periapical each additional radiographic image |
648 |
613 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
33 |
13 |
$3K |