| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0274 |
Bitewings - four radiographic images |
389 |
388 |
$5K |
| D0120 |
Periodic oral evaluation - established patient |
337 |
337 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
826 |
800 |
$4K |
| D0140 |
Limited oral evaluation - problem focused |
356 |
347 |
$4K |
| D1120 |
Prophylaxis - child |
162 |
162 |
$4K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
156 |
156 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
187 |
187 |
$1K |
| D1110 |
Prophylaxis - adult |
31 |
31 |
$1K |
| D0330 |
Panoramic radiographic image |
64 |
64 |
$1K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
17 |
13 |
$566.52 |
| D0270 |
|
89 |
88 |
$498.81 |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
17 |
16 |
$486.53 |
| D0230 |
Intraoral - periapical each additional radiographic image |
82 |
82 |
$374.40 |
| D0240 |
|
29 |
17 |
$209.24 |
| D0272 |
Bitewings - two radiographic images |
15 |
15 |
$92.62 |
| D1310 |
|
108 |
108 |
$0.00 |
| D1330 |
|
143 |
143 |
$0.00 |
| D0999 |
Unspecified diagnostic procedure, by report |
30 |
30 |
$0.00 |