| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
369 |
368 |
$23K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
196 |
99 |
$5K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
49 |
27 |
$3K |
| D0210 |
Intraoral - complete series of radiographic images |
26 |
26 |
$3K |
| D0330 |
Panoramic radiographic image |
98 |
98 |
$1K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
46 |
26 |
$806.32 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
52 |
52 |
$312.66 |
| D0274 |
Bitewings - four radiographic images |
240 |
240 |
$162.22 |
| D0220 |
Intraoral - periapical first radiographic image |
121 |
115 |
$26.63 |
| D0120 |
Periodic oral evaluation - established patient |
242 |
242 |
$9.22 |
| D1208 |
Topical application of fluoride, excluding varnish |
162 |
162 |
$0.00 |