| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
385 |
384 |
$13K |
| D0120 |
Periodic oral evaluation - established patient |
459 |
459 |
$9K |
| D0274 |
Bitewings - four radiographic images |
279 |
279 |
$7K |
| D0210 |
Intraoral - complete series of radiographic images |
107 |
107 |
$5K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
224 |
223 |
$4K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
40 |
24 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
249 |
240 |
$2K |
| D0330 |
Panoramic radiographic image |
46 |
46 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
109 |
106 |
$855.12 |
| D1208 |
Topical application of fluoride, excluding varnish |
48 |
48 |
$769.61 |
| D1120 |
Prophylaxis - child |
28 |
28 |
$617.38 |
| D1330 |
|
83 |
83 |
$415.00 |
| D0602 |
|
15 |
15 |
$150.00 |