| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
217 |
215 |
$6K |
| D1110 |
Prophylaxis - adult |
121 |
119 |
$5K |
| D0330 |
Panoramic radiographic image |
125 |
124 |
$5K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
35 |
12 |
$3K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
36 |
12 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
39 |
39 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
63 |
62 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
312 |
276 |
$560.00 |
| D1120 |
Prophylaxis - child |
12 |
12 |
$540.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
245 |
209 |
$288.00 |
| D0140 |
Limited oral evaluation - problem focused |
14 |
13 |
$144.00 |
| D0274 |
Bitewings - four radiographic images |
12 |
12 |
$144.00 |
| D1330 |
|
281 |
248 |
$0.00 |