| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
850 |
848 |
$14K |
| D0120 |
Periodic oral evaluation - established patient |
813 |
813 |
$13K |
| D0230 |
Intraoral - periapical each additional radiographic image |
868 |
858 |
$6K |
| D0220 |
Intraoral - periapical first radiographic image |
974 |
960 |
$3K |
| D0272 |
Bitewings - two radiographic images |
315 |
315 |
$2K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
46 |
30 |
$1K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
60 |
40 |
$1K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
41 |
31 |
$1K |
| D0274 |
Bitewings - four radiographic images |
241 |
241 |
$1K |