| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
532 |
531 |
$24K |
| D0120 |
Periodic oral evaluation - established patient |
337 |
336 |
$8K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
78 |
39 |
$5K |
| D0274 |
Bitewings - four radiographic images |
459 |
459 |
$5K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
98 |
37 |
$5K |
| D0210 |
Intraoral - complete series of radiographic images |
103 |
103 |
$5K |
| D0140 |
Limited oral evaluation - problem focused |
103 |
103 |
$5K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
173 |
173 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
825 |
821 |
$4K |
| D0230 |
Intraoral - periapical each additional radiographic image |
598 |
596 |
$2K |
| D1206 |
Topical application of fluoride varnish |
47 |
47 |
$1K |
| D0330 |
Panoramic radiographic image |
16 |
16 |
$640.00 |