| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
230 |
230 |
$6K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
65 |
34 |
$4K |
| D1110 |
Prophylaxis - adult |
143 |
143 |
$3K |
| D0330 |
Panoramic radiographic image |
71 |
71 |
$3K |
| D0274 |
Bitewings - four radiographic images |
182 |
181 |
$2K |
| D1120 |
Prophylaxis - child |
101 |
101 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
59 |
59 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
128 |
128 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
71 |
70 |
$1K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
19 |
14 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
238 |
230 |
$942.00 |
| D2330 |
|
44 |
26 |
$925.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
133 |
132 |
$552.00 |
| D0272 |
Bitewings - two radiographic images |
59 |
59 |
$472.00 |
| D9210 |
|
15 |
15 |
$130.00 |