| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
3,117 |
3,113 |
$155K |
| D0210 |
Intraoral - complete series of radiographic images |
1,385 |
1,385 |
$71K |
| D0120 |
Periodic oral evaluation - established patient |
2,434 |
2,432 |
$64K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
757 |
756 |
$22K |
| D0274 |
Bitewings - four radiographic images |
863 |
861 |
$22K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
253 |
211 |
$20K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
104 |
73 |
$6K |