| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
195 |
195 |
$10K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
81 |
64 |
$7K |
| D0120 |
Periodic oral evaluation - established patient |
184 |
184 |
$5K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
49 |
33 |
$5K |
| D0274 |
Bitewings - four radiographic images |
128 |
128 |
$3K |
| D0330 |
Panoramic radiographic image |
59 |
59 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
45 |
45 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
62 |
62 |
$601.17 |
| D0140 |
Limited oral evaluation - problem focused |
44 |
44 |
$593.60 |
| D1120 |
Prophylaxis - child |
14 |
14 |
$578.35 |
| D1208 |
Topical application of fluoride, excluding varnish |
18 |
18 |
$241.50 |