| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
888 |
888 |
$48K |
| D0120 |
Periodic oral evaluation - established patient |
834 |
834 |
$24K |
| D0274 |
Bitewings - four radiographic images |
390 |
390 |
$10K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
87 |
78 |
$9K |
| D0330 |
Panoramic radiographic image |
214 |
214 |
$7K |
| D1120 |
Prophylaxis - child |
140 |
140 |
$6K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
204 |
204 |
$6K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
48 |
43 |
$4K |
| D1208 |
Topical application of fluoride, excluding varnish |
164 |
164 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
109 |
106 |
$1K |
| D0210 |
Intraoral - complete series of radiographic images |
41 |
41 |
$716.00 |
| D0272 |
Bitewings - two radiographic images |
13 |
13 |
$221.00 |
| D0140 |
Limited oral evaluation - problem focused |
12 |
12 |
$154.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
12 |
12 |
$141.00 |