| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0140 |
Limited oral evaluation - problem focused |
560 |
551 |
$45K |
| D0120 |
Periodic oral evaluation - established patient |
738 |
738 |
$45K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
309 |
309 |
$25K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
70 |
67 |
$8K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
79 |
74 |
$5K |
| D1110 |
Prophylaxis - adult |
24 |
24 |
$626.95 |
| D1120 |
Prophylaxis - child |
308 |
308 |
$543.99 |
| D0220 |
Intraoral - periapical first radiographic image |
237 |
232 |
$376.17 |
| D1206 |
Topical application of fluoride varnish |
296 |
296 |
$308.10 |
| D0274 |
Bitewings - four radiographic images |
178 |
178 |
$0.00 |
| D0330 |
Panoramic radiographic image |
48 |
48 |
$0.00 |
| D0603 |
|
42 |
42 |
$0.00 |
| D0272 |
Bitewings - two radiographic images |
13 |
13 |
$0.00 |
| D9999 |
Unspecified adjunctive procedure, by report |
18 |
18 |
$0.00 |
| D0602 |
|
26 |
26 |
$0.00 |