| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,053 |
1,052 |
$36K |
| D0274 |
Bitewings - four radiographic images |
1,260 |
1,258 |
$18K |
| D0330 |
Panoramic radiographic image |
635 |
635 |
$16K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
207 |
143 |
$13K |
| D0120 |
Periodic oral evaluation - established patient |
637 |
636 |
$12K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
517 |
517 |
$12K |
| D1120 |
Prophylaxis - child |
213 |
213 |
$7K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
157 |
109 |
$7K |
| D0220 |
Intraoral - periapical first radiographic image |
1,535 |
1,456 |
$7K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,493 |
1,473 |
$7K |
| D0140 |
Limited oral evaluation - problem focused |
215 |
212 |
$2K |
| D1206 |
Topical application of fluoride varnish |
375 |
374 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
161 |
161 |
$1K |
| D0270 |
|
16 |
15 |
$64.00 |