| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,572 |
1,571 |
$56K |
| D0330 |
Panoramic radiographic image |
640 |
639 |
$16K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
738 |
738 |
$16K |
| D0120 |
Periodic oral evaluation - established patient |
768 |
767 |
$14K |
| D0350 |
|
1,031 |
1,031 |
$9K |
| D0274 |
Bitewings - four radiographic images |
521 |
519 |
$9K |
| D0220 |
Intraoral - periapical first radiographic image |
1,609 |
1,517 |
$8K |
| D0230 |
Intraoral - periapical each additional radiographic image |
815 |
786 |
$5K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
85 |
32 |
$4K |
| D1120 |
Prophylaxis - child |
48 |
48 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
56 |
50 |
$736.25 |
| D1208 |
Topical application of fluoride, excluding varnish |
27 |
27 |
$308.00 |
| D0431 |
|
150 |
150 |
$0.00 |
| D1310 |
|
620 |
620 |
$0.00 |
| D1330 |
|
623 |
623 |
$0.00 |