| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0140 |
Limited oral evaluation - problem focused |
164 |
126 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
75 |
74 |
$3K |
| D1110 |
Prophylaxis - adult |
80 |
78 |
$3K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
24 |
12 |
$3K |
| D1208 |
Topical application of fluoride, excluding varnish |
105 |
105 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
302 |
221 |
$2K |
| D0120 |
Periodic oral evaluation - established patient |
66 |
65 |
$1K |
| D0330 |
Panoramic radiographic image |
31 |
31 |
$1K |
| D1120 |
Prophylaxis - child |
15 |
15 |
$635.55 |
| D0274 |
Bitewings - four radiographic images |
14 |
14 |
$243.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
40 |
26 |
$239.06 |
| D0270 |
|
12 |
12 |
$98.44 |
| D1330 |
|
13 |
13 |
$78.00 |