| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
224 |
224 |
$12K |
| D0120 |
Periodic oral evaluation - established patient |
187 |
187 |
$5K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
76 |
76 |
$3K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
21 |
12 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
148 |
143 |
$2K |
| D0274 |
Bitewings - four radiographic images |
66 |
66 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
159 |
82 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
25 |
24 |
$1K |
| D1120 |
Prophylaxis - child |
29 |
29 |
$1K |
| D0330 |
Panoramic radiographic image |
12 |
12 |
$760.00 |
| D0210 |
Intraoral - complete series of radiographic images |
13 |
13 |
$711.09 |
| D1206 |
Topical application of fluoride varnish |
12 |
12 |
$341.46 |