| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
170 |
170 |
$5K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
144 |
144 |
$4K |
| D0330 |
Panoramic radiographic image |
77 |
77 |
$3K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
55 |
34 |
$3K |
| D0274 |
Bitewings - four radiographic images |
165 |
165 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
105 |
104 |
$2K |
| D0120 |
Periodic oral evaluation - established patient |
130 |
130 |
$2K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
16 |
13 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
217 |
215 |
$990.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
61 |
61 |
$900.00 |
| D1206 |
Topical application of fluoride varnish |
64 |
64 |
$855.00 |
| D0210 |
Intraoral - complete series of radiographic images |
14 |
14 |
$825.00 |
| D1120 |
Prophylaxis - child |
41 |
41 |
$820.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
180 |
130 |
$785.00 |
| D1320 |
|
30 |
30 |
$420.00 |