| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
359 |
357 |
$15K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
267 |
265 |
$10K |
| D0120 |
Periodic oral evaluation - established patient |
366 |
363 |
$9K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
40 |
24 |
$6K |
| D0220 |
Intraoral - periapical first radiographic image |
327 |
323 |
$4K |
| D1206 |
Topical application of fluoride varnish |
207 |
206 |
$4K |
| D0230 |
Intraoral - periapical each additional radiographic image |
170 |
169 |
$3K |
| D0210 |
Intraoral - complete series of radiographic images |
64 |
63 |
$3K |
| D0330 |
Panoramic radiographic image |
12 |
12 |
$597.36 |
| D1120 |
Prophylaxis - child |
15 |
15 |
$490.68 |
| D0274 |
Bitewings - four radiographic images |
13 |
13 |
$357.73 |