| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
214 |
214 |
$12K |
| D0274 |
Bitewings - four radiographic images |
215 |
215 |
$5K |
| D0330 |
Panoramic radiographic image |
138 |
138 |
$4K |
| D0120 |
Periodic oral evaluation - established patient |
151 |
151 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
232 |
228 |
$4K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
109 |
109 |
$3K |
| D1120 |
Prophylaxis - child |
49 |
49 |
$2K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
17 |
12 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
81 |
81 |
$1K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
17 |
12 |
$925.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
32 |
32 |
$791.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
30 |
30 |
$416.00 |
| D1330 |
|
12 |
12 |
$0.00 |