| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
81 |
80 |
$4K |
| D0210 |
Intraoral - complete series of radiographic images |
93 |
90 |
$3K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
85 |
41 |
$3K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
29 |
16 |
$3K |
| D0330 |
Panoramic radiographic image |
13 |
13 |
$644.77 |
| D0120 |
Periodic oral evaluation - established patient |
89 |
88 |
$578.47 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
171 |
168 |
$551.83 |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
24 |
12 |
$400.61 |
| D0274 |
Bitewings - four radiographic images |
64 |
64 |
$328.03 |
| D0350 |
|
230 |
223 |
$109.39 |
| D1208 |
Topical application of fluoride, excluding varnish |
162 |
160 |
$10.00 |