| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
483 |
479 |
$26K |
| D0274 |
Bitewings - four radiographic images |
417 |
417 |
$13K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
85 |
43 |
$10K |
| D0210 |
Intraoral - complete series of radiographic images |
230 |
219 |
$9K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
205 |
205 |
$8K |
| D0330 |
Panoramic radiographic image |
90 |
90 |
$6K |
| D0120 |
Periodic oral evaluation - established patient |
249 |
249 |
$6K |
| D1208 |
Topical application of fluoride, excluding varnish |
118 |
118 |
$3K |
| D1120 |
Prophylaxis - child |
65 |
65 |
$3K |
| D9920 |
|
14 |
12 |
$574.00 |
| D0140 |
Limited oral evaluation - problem focused |
13 |
13 |
$419.64 |
| D0220 |
Intraoral - periapical first radiographic image |
24 |
24 |
$348.72 |