| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
626 |
619 |
$27K |
| D0120 |
Periodic oral evaluation - established patient |
588 |
583 |
$14K |
| D0274 |
Bitewings - four radiographic images |
184 |
184 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
357 |
355 |
$2K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
23 |
13 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
19 |
12 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
167 |
167 |
$501.00 |