| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
247 |
244 |
$3K |
| D0330 |
Panoramic radiographic image |
92 |
91 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
126 |
123 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
563 |
330 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
534 |
497 |
$2K |
| D0274 |
Bitewings - four radiographic images |
195 |
192 |
$2K |
| D0120 |
Periodic oral evaluation - established patient |
243 |
243 |
$890.80 |
| D1208 |
Topical application of fluoride, excluding varnish |
73 |
73 |
$837.93 |
| D1120 |
Prophylaxis - child |
14 |
14 |
$610.12 |
| D0140 |
Limited oral evaluation - problem focused |
56 |
56 |
$355.08 |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
25 |
12 |
$0.00 |