| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,079 |
1,077 |
$49K |
| D0120 |
Periodic oral evaluation - established patient |
615 |
615 |
$14K |
| D0274 |
Bitewings - four radiographic images |
467 |
467 |
$11K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
165 |
121 |
$10K |
| D0220 |
Intraoral - periapical first radiographic image |
616 |
616 |
$7K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
257 |
257 |
$6K |
| D0230 |
Intraoral - periapical each additional radiographic image |
540 |
532 |
$6K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
95 |
75 |
$5K |
| D0210 |
Intraoral - complete series of radiographic images |
57 |
57 |
$3K |