| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
785 |
775 |
$26K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
184 |
56 |
$13K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
350 |
344 |
$10K |
| D0120 |
Periodic oral evaluation - established patient |
750 |
741 |
$10K |
| D0274 |
Bitewings - four radiographic images |
351 |
343 |
$7K |
| D0210 |
Intraoral - complete series of radiographic images |
264 |
142 |
$4K |
| D0330 |
Panoramic radiographic image |
39 |
39 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
97 |
95 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
190 |
179 |
$2K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
22 |
13 |
$0.00 |
| D2740 |
Crown - porcelain/ceramic |
14 |
12 |
$0.00 |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
41 |
12 |
$0.00 |