| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,183 |
1,181 |
$63K |
| D0120 |
Periodic oral evaluation - established patient |
1,051 |
1,048 |
$28K |
| D0274 |
Bitewings - four radiographic images |
665 |
665 |
$22K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
225 |
97 |
$17K |
| D0330 |
Panoramic radiographic image |
179 |
179 |
$9K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
282 |
282 |
$8K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
79 |
35 |
$4K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
20 |
14 |
$2K |
| D1120 |
Prophylaxis - child |
45 |
45 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
83 |
82 |
$1K |
| D0210 |
Intraoral - complete series of radiographic images |
12 |
12 |
$912.00 |
| D0220 |
Intraoral - periapical first radiographic image |
15 |
12 |
$157.70 |