| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,627 |
1,627 |
$57K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,581 |
1,579 |
$26K |
| D0120 |
Periodic oral evaluation - established patient |
810 |
810 |
$16K |
| D0220 |
Intraoral - periapical first radiographic image |
1,669 |
1,668 |
$15K |
| D0210 |
Intraoral - complete series of radiographic images |
1,189 |
1,187 |
$12K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
396 |
396 |
$8K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
161 |
104 |
$8K |
| D0274 |
Bitewings - four radiographic images |
253 |
253 |
$5K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
12 |
12 |
$966.62 |