| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
404 |
395 |
$3K |
| D0330 |
Panoramic radiographic image |
194 |
184 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
201 |
193 |
$2K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
265 |
154 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
857 |
443 |
$2K |
| D0274 |
Bitewings - four radiographic images |
328 |
320 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
583 |
557 |
$871.80 |
| D4346 |
|
13 |
13 |
$797.55 |
| D1208 |
Topical application of fluoride, excluding varnish |
277 |
270 |
$756.84 |
| D0120 |
Periodic oral evaluation - established patient |
412 |
403 |
$707.40 |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
35 |
26 |
$0.00 |
| D1120 |
Prophylaxis - child |
12 |
12 |
$0.00 |
| D2950 |
|
12 |
12 |
$0.00 |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
42 |
28 |
$0.00 |
| D0140 |
Limited oral evaluation - problem focused |
13 |
12 |
$0.00 |