| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
373 |
373 |
$12K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
176 |
97 |
$10K |
| D0274 |
Bitewings - four radiographic images |
385 |
385 |
$10K |
| D0120 |
Periodic oral evaluation - established patient |
437 |
437 |
$8K |
| D0330 |
Panoramic radiographic image |
162 |
162 |
$5K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
81 |
43 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
468 |
466 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
377 |
376 |
$3K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
18 |
13 |
$1K |
| D1208 |
Topical application of fluoride, excluding varnish |
47 |
47 |
$789.12 |
| D0140 |
Limited oral evaluation - problem focused |
35 |
35 |
$702.54 |
| D1310 |
|
51 |
51 |
$358.61 |
| D1330 |
|
49 |
49 |
$308.24 |