| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,562 |
1,562 |
$81K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
500 |
306 |
$43K |
| D0120 |
Periodic oral evaluation - established patient |
1,080 |
1,080 |
$29K |
| D0274 |
Bitewings - four radiographic images |
1,031 |
1,031 |
$27K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
406 |
260 |
$27K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
655 |
655 |
$19K |
| D0210 |
Intraoral - complete series of radiographic images |
294 |
294 |
$9K |
| D0330 |
Panoramic radiographic image |
152 |
152 |
$5K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
32 |
28 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
63 |
63 |
$733.89 |
| D1208 |
Topical application of fluoride, excluding varnish |
12 |
12 |
$168.00 |
| D1999 |
|
211 |
194 |
$0.00 |