| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
385 |
310 |
$16K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
423 |
357 |
$15K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
103 |
38 |
$8K |
| D0330 |
Panoramic radiographic image |
188 |
151 |
$6K |
| D0210 |
Intraoral - complete series of radiographic images |
214 |
184 |
$5K |
| D0120 |
Periodic oral evaluation - established patient |
140 |
127 |
$3K |
| D1206 |
Topical application of fluoride varnish |
136 |
112 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
28 |
15 |
$2K |
| D0274 |
Bitewings - four radiographic images |
44 |
35 |
$892.21 |
| D1120 |
Prophylaxis - child |
27 |
27 |
$880.46 |
| D0220 |
Intraoral - periapical first radiographic image |
27 |
27 |
$329.16 |
| D0230 |
Intraoral - periapical each additional radiographic image |
31 |
13 |
$248.00 |