| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
836 |
836 |
$36K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
206 |
106 |
$18K |
| D0120 |
Periodic oral evaluation - established patient |
608 |
605 |
$14K |
| D0210 |
Intraoral - complete series of radiographic images |
238 |
238 |
$12K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
301 |
301 |
$8K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
38 |
26 |
$5K |
| D0274 |
Bitewings - four radiographic images |
191 |
191 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
277 |
274 |
$3K |
| D0330 |
Panoramic radiographic image |
39 |
39 |
$1K |
| D1208 |
Topical application of fluoride, excluding varnish |
58 |
58 |
$912.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
61 |
60 |
$355.65 |
| D0140 |
Limited oral evaluation - problem focused |
13 |
13 |
$211.75 |