| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
494 |
494 |
$13K |
| D1110 |
Prophylaxis - adult |
203 |
203 |
$8K |
| D1120 |
Prophylaxis - child |
123 |
123 |
$5K |
| D0274 |
Bitewings - four radiographic images |
296 |
296 |
$4K |
| D1208 |
Topical application of fluoride, excluding varnish |
185 |
185 |
$4K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
54 |
28 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
448 |
441 |
$2K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
31 |
15 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
381 |
379 |
$2K |
| D0330 |
Panoramic radiographic image |
40 |
40 |
$1K |
| D0272 |
Bitewings - two radiographic images |
46 |
46 |
$460.00 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
12 |
12 |
$384.00 |
| D0140 |
Limited oral evaluation - problem focused |
13 |
13 |
$299.00 |