| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
669 |
669 |
$53K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
116 |
51 |
$7K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
97 |
97 |
$4K |
| D1120 |
Prophylaxis - child |
27 |
27 |
$2K |
| D0330 |
Panoramic radiographic image |
24 |
24 |
$1K |
| D0274 |
Bitewings - four radiographic images |
346 |
345 |
$335.57 |
| D0220 |
Intraoral - periapical first radiographic image |
1,097 |
1,057 |
$138.66 |
| D0140 |
Limited oral evaluation - problem focused |
13 |
12 |
$102.47 |
| D0120 |
Periodic oral evaluation - established patient |
639 |
639 |
$38.48 |
| D1208 |
Topical application of fluoride, excluding varnish |
40 |
40 |
$0.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,052 |
667 |
$0.00 |
| D0272 |
Bitewings - two radiographic images |
25 |
25 |
$0.00 |