| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
159 |
157 |
$6K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
155 |
151 |
$5K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
70 |
33 |
$5K |
| D0330 |
Panoramic radiographic image |
67 |
67 |
$4K |
| D0210 |
Intraoral - complete series of radiographic images |
36 |
33 |
$3K |
| D0120 |
Periodic oral evaluation - established patient |
59 |
59 |
$973.56 |
| D0220 |
Intraoral - periapical first radiographic image |
161 |
159 |
$920.07 |
| D0230 |
Intraoral - periapical each additional radiographic image |
109 |
102 |
$626.60 |
| D1208 |
Topical application of fluoride, excluding varnish |
25 |
25 |
$548.76 |
| D0274 |
Bitewings - four radiographic images |
14 |
14 |
$140.00 |