| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
93 |
93 |
$3K |
| D0120 |
Periodic oral evaluation - established patient |
97 |
97 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
50 |
49 |
$2K |
| D0272 |
Bitewings - two radiographic images |
100 |
99 |
$2K |
| D0330 |
Panoramic radiographic image |
42 |
42 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
30 |
12 |
$2K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
24 |
14 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
103 |
102 |
$840.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
96 |
96 |
$780.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
48 |
48 |
$734.00 |