| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0330 |
Panoramic radiographic image |
276 |
271 |
$13K |
| D1110 |
Prophylaxis - adult |
222 |
215 |
$5K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
370 |
360 |
$5K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
86 |
52 |
$4K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
110 |
57 |
$2K |
| D1120 |
Prophylaxis - child |
14 |
14 |
$199.00 |
| D0274 |
Bitewings - four radiographic images |
322 |
317 |
$85.26 |
| D0210 |
Intraoral - complete series of radiographic images |
32 |
31 |
$48.00 |
| D1330 |
|
40 |
40 |
$20.95 |
| D1208 |
Topical application of fluoride, excluding varnish |
43 |
43 |
$15.26 |
| D0220 |
Intraoral - periapical first radiographic image |
13 |
13 |
$0.00 |