| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
907 |
907 |
$27K |
| D0274 |
Bitewings - four radiographic images |
746 |
743 |
$11K |
| D0330 |
Panoramic radiographic image |
465 |
464 |
$11K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
547 |
546 |
$9K |
| D0120 |
Periodic oral evaluation - established patient |
287 |
286 |
$5K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
62 |
25 |
$3K |
| D2330 |
|
53 |
12 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
216 |
216 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
34 |
13 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
208 |
208 |
$1K |
| D9110 |
|
53 |
53 |
$740.92 |
| D0230 |
Intraoral - periapical each additional radiographic image |
122 |
122 |
$492.67 |
| D0210 |
Intraoral - complete series of radiographic images |
17 |
17 |
$443.68 |