| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,573 |
1,571 |
$66K |
| D0120 |
Periodic oral evaluation - established patient |
1,203 |
1,201 |
$28K |
| D0274 |
Bitewings - four radiographic images |
986 |
985 |
$22K |
| D0220 |
Intraoral - periapical first radiographic image |
1,126 |
1,124 |
$9K |
| D0210 |
Intraoral - complete series of radiographic images |
187 |
186 |
$7K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,046 |
1,041 |
$6K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
104 |
49 |
$5K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
95 |
95 |
$2K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
16 |
12 |
$801.33 |