| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
482 |
478 |
$20K |
| D0120 |
Periodic oral evaluation - established patient |
439 |
434 |
$10K |
| D0220 |
Intraoral - periapical first radiographic image |
288 |
275 |
$4K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
15 |
12 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
125 |
119 |
$873.90 |
| D0210 |
Intraoral - complete series of radiographic images |
12 |
12 |
$477.00 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
17 |
17 |
$450.00 |
| D0274 |
Bitewings - four radiographic images |
14 |
13 |
$389.00 |