| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
187 |
187 |
$5K |
| D0120 |
Periodic oral evaluation - established patient |
258 |
258 |
$4K |
| D1120 |
Prophylaxis - child |
124 |
124 |
$3K |
| D1208 |
Topical application of fluoride, excluding varnish |
139 |
139 |
$2K |
| D0330 |
Panoramic radiographic image |
97 |
97 |
$2K |
| D0274 |
Bitewings - four radiographic images |
219 |
219 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
58 |
58 |
$750.00 |
| D0140 |
Limited oral evaluation - problem focused |
29 |
28 |
$675.00 |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
16 |
12 |
$490.00 |
| D0272 |
Bitewings - two radiographic images |
71 |
71 |
$480.00 |
| D0601 |
|
15 |
15 |
$150.00 |
| D0220 |
Intraoral - periapical first radiographic image |
31 |
31 |
$70.00 |