| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
126 |
126 |
$4K |
| D1110 |
Prophylaxis - adult |
91 |
91 |
$4K |
| D1208 |
Topical application of fluoride, excluding varnish |
181 |
181 |
$3K |
| D0274 |
Bitewings - four radiographic images |
99 |
99 |
$3K |
| D1120 |
Prophylaxis - child |
86 |
86 |
$3K |
| D0330 |
Panoramic radiographic image |
51 |
51 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
189 |
187 |
$2K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
29 |
20 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
178 |
177 |
$2K |
| D0272 |
Bitewings - two radiographic images |
64 |
64 |
$1K |
| D0120 |
Periodic oral evaluation - established patient |
56 |
56 |
$1K |