| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
557 |
557 |
$25K |
| D0120 |
Periodic oral evaluation - established patient |
658 |
657 |
$19K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
113 |
54 |
$8K |
| D0330 |
Panoramic radiographic image |
139 |
138 |
$6K |
| D0274 |
Bitewings - four radiographic images |
473 |
469 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
1,198 |
1,152 |
$5K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
93 |
93 |
$4K |
| D1120 |
Prophylaxis - child |
71 |
71 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,000 |
965 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
53 |
25 |
$3K |
| D1206 |
Topical application of fluoride varnish |
61 |
61 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
40 |
40 |
$480.00 |
| D1330 |
|
127 |
112 |
$0.00 |