| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
1,644 |
1,637 |
$11K |
| D1110 |
Prophylaxis - adult |
700 |
700 |
$8K |
| D1120 |
Prophylaxis - child |
937 |
937 |
$7K |
| D0330 |
Panoramic radiographic image |
418 |
418 |
$4K |
| D1208 |
Topical application of fluoride, excluding varnish |
911 |
911 |
$4K |
| D0274 |
Bitewings - four radiographic images |
856 |
855 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
173 |
55 |
$1K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
122 |
122 |
$975.00 |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
57 |
27 |
$280.00 |
| D0140 |
Limited oral evaluation - problem focused |
12 |
12 |
$180.00 |