| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
476 |
433 |
$22K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
125 |
68 |
$11K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
139 |
68 |
$11K |
| D0140 |
Limited oral evaluation - problem focused |
332 |
314 |
$11K |
| D0210 |
Intraoral - complete series of radiographic images |
329 |
202 |
$9K |
| D0330 |
Panoramic radiographic image |
145 |
122 |
$7K |
| D0120 |
Periodic oral evaluation - established patient |
314 |
287 |
$7K |
| D0274 |
Bitewings - four radiographic images |
215 |
188 |
$7K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
191 |
174 |
$6K |
| D0220 |
Intraoral - periapical first radiographic image |
357 |
304 |
$4K |
| D1206 |
Topical application of fluoride varnish |
59 |
57 |
$956.75 |
| D0230 |
Intraoral - periapical each additional radiographic image |
65 |
12 |
$603.00 |
| D1999 |
|
20 |
14 |
$270.00 |