| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
393 |
356 |
$19K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
93 |
67 |
$7K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
90 |
56 |
$5K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
81 |
70 |
$3K |
| D0274 |
Bitewings - four radiographic images |
79 |
72 |
$3K |
| D0330 |
Panoramic radiographic image |
45 |
43 |
$3K |
| D0120 |
Periodic oral evaluation - established patient |
88 |
85 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
18 |
13 |
$246.29 |
| D0230 |
Intraoral - periapical each additional radiographic image |
27 |
12 |
$149.00 |
| D0220 |
Intraoral - periapical first radiographic image |
19 |
13 |
$131.19 |