| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,250 |
1,244 |
$55K |
| D0120 |
Periodic oral evaluation - established patient |
1,048 |
1,042 |
$25K |
| D0230 |
Intraoral - periapical each additional radiographic image |
542 |
537 |
$13K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
89 |
56 |
$12K |
| D0220 |
Intraoral - periapical first radiographic image |
715 |
707 |
$9K |
| D0274 |
Bitewings - four radiographic images |
254 |
254 |
$7K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
23 |
12 |
$3K |
| D0210 |
Intraoral - complete series of radiographic images |
29 |
29 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
39 |
39 |
$2K |