| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
458 |
458 |
$15K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
239 |
123 |
$13K |
| D0274 |
Bitewings - four radiographic images |
428 |
426 |
$11K |
| D9110 |
|
310 |
306 |
$9K |
| D0120 |
Periodic oral evaluation - established patient |
466 |
466 |
$9K |
| D0220 |
Intraoral - periapical first radiographic image |
694 |
676 |
$5K |
| D0230 |
Intraoral - periapical each additional radiographic image |
430 |
426 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
169 |
167 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
55 |
26 |
$2K |
| D0330 |
Panoramic radiographic image |
30 |
30 |
$1K |
| D0601 |
|
59 |
59 |
$580.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
28 |
28 |
$451.82 |
| D1330 |
|
72 |
72 |
$374.35 |
| D1310 |
|
37 |
37 |
$197.95 |
| D0140 |
Limited oral evaluation - problem focused |
12 |
12 |
$181.98 |