| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,254 |
1,251 |
$62K |
| D0120 |
Periodic oral evaluation - established patient |
1,222 |
1,217 |
$31K |
| D0274 |
Bitewings - four radiographic images |
569 |
567 |
$14K |
| D0330 |
Panoramic radiographic image |
208 |
208 |
$7K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
58 |
37 |
$4K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
165 |
158 |
$4K |
| D2394 |
|
18 |
13 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
57 |
55 |
$481.50 |
| D0230 |
Intraoral - periapical each additional radiographic image |
27 |
13 |
$118.00 |