| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
653 |
653 |
$21K |
| D0120 |
Periodic oral evaluation - established patient |
775 |
773 |
$15K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
339 |
177 |
$14K |
| D0274 |
Bitewings - four radiographic images |
517 |
515 |
$13K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
196 |
128 |
$10K |
| D0220 |
Intraoral - periapical first radiographic image |
701 |
692 |
$5K |
| D0230 |
Intraoral - periapical each additional radiographic image |
608 |
585 |
$5K |
| D9110 |
|
102 |
100 |
$3K |
| D0210 |
Intraoral - complete series of radiographic images |
25 |
25 |
$1K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
33 |
33 |
$632.10 |