| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
338 |
337 |
$19K |
| D0274 |
Bitewings - four radiographic images |
419 |
419 |
$9K |
| D0220 |
Intraoral - periapical first radiographic image |
361 |
356 |
$7K |
| D0120 |
Periodic oral evaluation - established patient |
173 |
172 |
$5K |
| D0330 |
Panoramic radiographic image |
104 |
104 |
$4K |
| D1120 |
Prophylaxis - child |
28 |
28 |
$1K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
19 |
13 |
$1K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
24 |
24 |
$689.00 |
| D0140 |
Limited oral evaluation - problem focused |
24 |
24 |
$308.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
14 |
14 |
$218.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
12 |
12 |
$167.00 |
| D1330 |
|
140 |
139 |
$0.00 |