| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,672 |
1,672 |
$70K |
| D0120 |
Periodic oral evaluation - established patient |
1,340 |
1,340 |
$31K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
300 |
209 |
$26K |
| D0274 |
Bitewings - four radiographic images |
984 |
984 |
$24K |
| D0220 |
Intraoral - periapical first radiographic image |
829 |
825 |
$13K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
460 |
460 |
$11K |
| D0330 |
Panoramic radiographic image |
266 |
266 |
$8K |
| D1208 |
Topical application of fluoride, excluding varnish |
406 |
406 |
$5K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
57 |
38 |
$4K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
21 |
13 |
$875.28 |
| D0230 |
Intraoral - periapical each additional radiographic image |
24 |
24 |
$279.30 |
| D1330 |
|
39 |
39 |
$0.00 |