| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
495 |
495 |
$28K |
| D1110 |
Prophylaxis - adult |
309 |
309 |
$21K |
| D0330 |
Panoramic radiographic image |
414 |
414 |
$19K |
| D0140 |
Limited oral evaluation - problem focused |
226 |
211 |
$11K |
| D1206 |
Topical application of fluoride varnish |
356 |
356 |
$9K |
| D0274 |
Bitewings - four radiographic images |
378 |
378 |
$9K |
| D0220 |
Intraoral - periapical first radiographic image |
569 |
508 |
$7K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
33 |
25 |
$4K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
23 |
13 |
$3K |
| D0120 |
Periodic oral evaluation - established patient |
98 |
98 |
$3K |
| D1120 |
Prophylaxis - child |
46 |
46 |
$2K |
| D1330 |
|
82 |
82 |
$590.40 |
| D0230 |
Intraoral - periapical each additional radiographic image |
55 |
53 |
$551.04 |