| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
456 |
452 |
$15K |
| D0274 |
Bitewings - four radiographic images |
274 |
272 |
$7K |
| D0120 |
Periodic oral evaluation - established patient |
334 |
334 |
$6K |
| D1320 |
|
336 |
336 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
498 |
464 |
$4K |
| D0230 |
Intraoral - periapical each additional radiographic image |
311 |
308 |
$2K |
| D1330 |
|
399 |
398 |
$2K |
| D1310 |
|
273 |
272 |
$2K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
27 |
13 |
$2K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
29 |
12 |
$1K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
71 |
70 |
$1K |