| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
820 |
820 |
$36K |
| D0330 |
Panoramic radiographic image |
437 |
437 |
$15K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
582 |
582 |
$13K |
| D0120 |
Periodic oral evaluation - established patient |
294 |
294 |
$6K |
| D0220 |
Intraoral - periapical first radiographic image |
510 |
510 |
$5K |
| D0272 |
Bitewings - two radiographic images |
218 |
218 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
340 |
340 |
$2K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
32 |
13 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
73 |
73 |
$2K |
| D9945 |
|
13 |
13 |
$1K |
| D1208 |
Topical application of fluoride, excluding varnish |
53 |
53 |
$604.75 |
| D0274 |
Bitewings - four radiographic images |
14 |
14 |
$212.54 |
| D0140 |
Limited oral evaluation - problem focused |
14 |
14 |
$155.74 |