| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
185 |
185 |
$6K |
| D0210 |
Intraoral - complete series of radiographic images |
131 |
127 |
$6K |
| D1206 |
Topical application of fluoride varnish |
532 |
529 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
187 |
183 |
$2K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
35 |
29 |
$2K |
| D0190 |
|
120 |
120 |
$1K |
| D0120 |
Periodic oral evaluation - established patient |
101 |
101 |
$1K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
54 |
37 |
$756.75 |
| D0274 |
Bitewings - four radiographic images |
75 |
75 |
$590.42 |
| D1120 |
Prophylaxis - child |
13 |
13 |
$377.19 |
| D0140 |
Limited oral evaluation - problem focused |
15 |
15 |
$182.74 |
| D0330 |
Panoramic radiographic image |
12 |
12 |
$155.59 |
| D1330 |
|
496 |
493 |
$25.09 |
| D0220 |
Intraoral - periapical first radiographic image |
240 |
237 |
$12.04 |
| D0230 |
Intraoral - periapical each additional radiographic image |
136 |
123 |
$4.46 |
| D9986 |
|
111 |
110 |
$0.00 |
| D1310 |
|
244 |
242 |
$0.00 |