| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
365 |
337 |
$11K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
143 |
139 |
$4K |
| D0210 |
Intraoral - complete series of radiographic images |
74 |
67 |
$3K |
| D0120 |
Periodic oral evaluation - established patient |
106 |
101 |
$2K |
| D0274 |
Bitewings - four radiographic images |
75 |
74 |
$1K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
20 |
13 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
113 |
105 |
$502.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
39 |
25 |
$128.00 |